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Date of Service (mm/dd/yyyy)

Time of Service

Fire District?
North Greece
Lakeshore
Barnard
Greece Ridge
Other
I don’t know

Which ambulance arrived at your location?
Greece Volunteer Ambulance
Monroe
Rural Metro
Other
I don’t know

The ambulance crew was polite and respectful.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Not applicable

Were you (the patient) transported to the hospital of your choice?
Yes
No, the preferred hospital was too busy
No, I was given a good medical reason
No - I don’t know why
I don’t know
I wasn't transported to the hospital

The ambulance crew appeared and acted in a professional manner.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
I don’t know
Not applicable

The ambulance crew understood and treated the illness/injury to my satisfaction.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Not applicable

I was satisfied with the ability of the ambulance crew to communicate with me in language I could understand.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Not applicable

The ambulance crew met all of my expectations.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Not applicable

My overall level of satisfaction with the ambulance service on this occasion was:
Very satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
Not applicable

How many times have you (the patient) used any ambulance service in the last 12 months?
Once
Between 2 and 5 times
More than 5 times
I don’t know
Not applicable

Gender (of the patient)
Male
Female

Please indicate the age group that you (the patient) fall into.
0 - 18
19 - 45
46 - 64
65 - older

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