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Client Satisfaction Survey
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Survey
1
Date of Call
Date of Call
Date of Call
Month/Date/Year
Number of times you (or someone on your behalf) called 911 in last 12 months
2.
Courtesy of the 911 call operator.
*
Excellent
Good
Fair
Poor
Not Applicable
Usefulness of instruction provided by the 911 call personnel prior to the arrival of Stettler EMS
*
Excellent
Good
Fair
Poor
Not Applicable
Professionalism/appearance of Stettler EMS personnel.
*
Excellent
Good
Fair
Poor
Not Applicable
Stettler EMS personnel's knowledge of your complaint.
Excellent
Good
Fair
Poor
Not Applicable
Quality of care provided by Stettler EMS personnel.
*
Excellent
Good
Fair
Poor
Not Applicable
Concern Stettler EMS personnel showed for your questions or worries.
*
Excellent
Good
Fair
Poor
Not Applicable
Concern Stettler EMS personnel showed for your family and friends.
*
Excellent
Good
Fair
Poor
Not Applicable
Degree to which Stettler EMS personnel explained the procedures they performed in a manner that you could understand.
*
Excellent
Good
Fair
Poor
Not Applicable
Cleanliness of the ambulance and equipment.
*
Excellent
Good
Fair
Poor
Not Applicable
Overall satisfaction with the service you received from Stettler EMS.
*
Excellent
Good
Fair
Poor
Not Applicable
Please rate the response time of Stettler EMS: 1 being Very Slow, 10 being Very Fast.
*
-- Select One --
10
9
8
7
6
5
4
3
2
1
3. Please offer any additional comments of suggestions in the space provided below.
4. If any members of our staff were especially helpful, please let us know who they are. We would like to show them our appreciation.
5. (Optional)
First Name
Last Name
Address1
Address2
City
Province
Postal Code
Phone Number
Email Address
Do you wish to be contacted by Stettler EMS regarding this survey?
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