North Benton Ambulance Patient Survey
Patient Satisfaction Survey
Name (optional)
Your answer
Patients Age *
Date patient was transported
MM
/
DD
/
YYYY
Hospital I was taken to: *
Are you: *
Pick up Location (town) *
Did the crew introduce themselves? *
The ambulance arrived in a timely manner: *
Strongly Disagree
Strongly Agree
Cleanliness of the ambulance: *
Very Dirty
Very Clean
Helpfulness of the EMS crew members *
Poor
Excellent
Care shown by the crew members who arrived with the ambulance: *
Very Poor
Excellent
Degree to which the crew members listened to you and/or your family: *
Very Poor
Excellent
Skill of the crew members: *
Very Poor
Excellent
Extent to which the crew members kept you informed about your treatment: *
Very Poor
Excellent
Extent to which crew members included you in the treatment decisions: (if applicable) *
Very Poor
Excellent
Degree to which the crew members relieved your pain or discomfort: *
Very Poor
Excellent
Crew members concern for your privacy: *
Very Poor
Excellent
Extent to which crew members cared for you as a person: *
Very Poor
Excellent
Professionalism of the crew members: *
Very Poor
Excellent
Overall rating of the care provided by our Emergency Medical Transportation service: *
Very Poor
Excellent
Would you recommend us to others? *
What could we do better the next time? Or if you would like to discuss any problems, please type your name and daytime telephone number, with area code, below.
Your answer
Do you have any additional comments not addressed by this survey?
Your answer
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