Client Satisfaction Survey

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:


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

    This field is not part of the form submission.

63. Submit

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