P.O. Box 911
Iselin, NJ 08830
Home
Organization
Members
Join Our Squad
Patient Survey
Links
Apparatus
News Articles
Hall Rental
Members ONLY
Staff ONLY
EMS Patient Survey
Please fill out the following form to help us with Quality Assurance:
Patient's Name:
Date of Call (mm/dd/yyyy):
Time of Call (hh:mm am/pm):
Please rate your experience below by choosing a number in the drop down box following each question. For any area you rate a "4" or "5" please breifly explain below so we may use your input to improve the quality of patient care of our service to the community.
Timeliness of Response:
1 - Excellent
2 - Good
3 - Average
4 - Below Average
5 - Poor
N/A
Crew Appearance:
1 - Excellent
2 - Good
3 - Average
4 - Below Average
5 - Poor
N/A
Cleanliness of Ambulance:
1 - Excellent
2 - Good
3 - Average
4 - Below Average
5 - Poor
N/A
Crew Professionalism:
1 - Excellent
2 - Good
3 - Average
4 - Below Average
5 - Poor
N/A
Crew Interaction with Patient:
1 - Excellent
2 - Good
3 - Average
4 - Below Average
5 - Poor
N/A
Crew Interaction with Family:
1 - Excellent
2 - Good
3 - Average
4 - Below Average
5 - Poor
N/A
Overall Care Received:
1 - Excellent
2 - Good
3 - Average
4 - Below Average
5 - Poor
N/A
Overall Experience with EMS:
1 - Excellent
2 - Good
3 - Average
4 - Below Average
5 - Poor
N/A
Please Explain any 4's or 5's:
If you called the billing office, please rate your experience with them:
Overall Experience with Billing Office:
1 - Excellent
2 - Good
3 - Average
4 - Below Average
5 - Poor
N/A
Other Comments:
Person completing form:
Relationship to Patient:
Your E-Mail:
Phone (if you want a return call):
Contact Us
Contact the
Webmaster
| © 2007
DigitalPFS.com
