JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
St Mary's County Advanced Life Support Patient Feedback
Sign in to Google
to save your progress.
Learn more
* Indicates required question
What was the Date and Time of the EMS Call?
*
MM
/
DD
/
YYYY
Which Rescue Squad Company was involved?
*
Leonardtown Volunteer Rescue Squad
Mechanicsville Volunteer Rescue Squard
Lexington Park Volunteer Rescue Squad
Ridge Volunteer Rescue Squad
Seventh District Volunteer Rescue Squad
Second District Volunteer Rescue Squad
Hollywood Volunteer Rescue Squad
Other:
What unit was involved
Your answer
Were you directly involved in the incident?
*
Yes
No
How long did you have to wait for EMS to arrive?
Less than 5 Minutes
5-9 Minutes
10-15 Minutes
Greater than 15 Minutes
Clear selection
How would you rate the professionalism/appearance of the EMS Provider(s)
Poor
1
2
3
4
5
Great
Clear selection
How would you rate the quality of the care you received?
Poor
1
2
3
4
5
Great
Clear selection
How would you rate the concern the EMS provider showed for your concern?
Poor
1
2
3
4
5
Great
Clear selection
How would you rate the the degree to which the provider explained what he or she was doing?
Poor
1
2
3
4
5
Great
Clear selection
Did you feel you were being listened to and heard?
Yes
No
Clear selection
How would you rate the cleanlinessof the ambulance and equipment?
Poor
1
2
3
4
5
Great
Clear selection
How would you rate your overall satisfaction with the care and treatment your received?
Poor
1
2
3
4
5
Great
Clear selection
Please provide details regarding the incident
*
Your answer
Please provide your contact information
Your answer
Would you like to be contacted regarding the resolution of this concern?
Yes
No
Clear selection
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
