Date of Service

-- mm/dd/yy

How was the timeliness of our response to your location?

4- excellent 3- good 2- fair 1- poor 0- N/A

How was the appearance of our crew?

4- excellent 3- good 2- fair 1- poor 0- n/a

How was the cleanliness of our ambulance?

4- excellent 3- good 2- fair 1- poor 0- n/a

How was the professionalism of our crew?

4-excellent 3- good 2- fair 1- poor 0- n/a

How would you rate the crew's interaction with you?

4-excellent 3- good 2- fair 1- poor 0- n/a

How did the crew interact with your family and/or friends?

4-excellent 3- good 2- fair 1- poor 0- n/a

How well did our staff explain billing forms and the privacy notice with you?

4-excellent 3- good 2- fair 1- poor 0- n/a

How would you rate your overall experience with Jersey Shore Area EMS?

4-excellent 3- good 2- fair 1- poor 0- n/a

If you interacted with our billing staff, rate your overall experience with them:

4-excellent 3- good 2- fair 1- poor 0- n/a

In order to help us improve the level of service that we provide, please explain any "4's" or "1's".

Name of person completing survey (optional):

Name

If you would like to be contacted, please include the following information (optional):

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
E-mail