2. 
3. 
4. Survey
9. 1
10. Date of Call
    Date of Call

    Date of Call
    Month/Date/Year
11. Number of times you (or someone on your behalf) called 911 in last 12 months
15. 2.
16. Courtesy of the 911 call operator.*

    1. Excellent
    2. Good
    3. Fair
    4. Poor
    5. Not Applicable
17. Usefulness of instruction provided by the 911 call personnel prior to the arrival of Stettler EMS*

    1. Excellent
    2. Good
    3. Fair
    4. Poor
    5. Not Applicable
19. Professionalism/appearance of Stettler EMS personnel.*

    1. Excellent
    2. Good
    3. Fair
    4. Poor
    5. Not Applicable
20. Stettler EMS personnel's knowledge of your complaint.

    1. Excellent
    2. Good
    3. Fair
    4. Poor
    5. Not Applicable
22. Quality of care provided by Stettler EMS personnel.*

    1. Excellent
    2. Good
    3. Fair
    4. Poor
    5. Not Applicable
24. Concern Stettler EMS personnel showed for your questions or worries.*

    1. Excellent
    2. Good
    3. Fair
    4. Poor
    5. Not Applicable
26. Concern Stettler EMS personnel showed for your family and friends.*

    1. Excellent
    2. Good
    3. Fair
    4. Poor
    5. Not Applicable
28. Degree to which Stettler EMS personnel explained the procedures they performed in a manner that you could understand.*

    1. Excellent
    2. Good
    3. Fair
    4. Poor
    5. Not Applicable
30. Cleanliness of the ambulance and equipment.*

    1. Excellent
    2. Good
    3. Fair
    4. Poor
    5. Not Applicable
32. Overall satisfaction with the service you received from Stettler EMS.*

    1. Excellent
    2. Good
    3. Fair
    4. Poor
    5. Not Applicable
34. Please rate the response time of Stettler EMS: 1 being Very Slow, 10 being Very Fast.*
    -- Select One --10987654321
38. 3. Please offer any additional comments of suggestions in the space provided below.
40. 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.
44. 5. (Optional)
46. First Name
47. Last Name
49. Address1
51. Address2
53. City
54. Province
55. Postal Code
57. Phone Number
58. Email Address
60. Do you wish to be contacted by Stettler EMS regarding this survey?

    1. Yes
    2. No
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

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