EMS Patient Feedback

EMS Patient Feedback
Did we recently respond to assist you or a member of your family? Please let us know how we did. We appreciate your honest feedback.
Please tell us for whom you are completing this survey

Family Friend Self Other
Date of Call

Month Day Year
Date
Incident Address
Number of times you, or someone else for you, has called 911 in the last 12 months:
Rate our Service
Professionalism and appearance of EMS personnel

Excellent Good Average Fair Poor
EMS personnel's knowledge of your complaint

Excellent Good Average Fair Poor
Quality of care provided by EMS personnel

Excellent Good Average Fair Poor
Concern EMS personnel showed for your questions or concerns

Excellent Good Average Fair Poor
Cleanliness of the ambulance and equipment

Excellent Good Average Fair Poor
Overall satisfaction with the service you received from the City of Manassas Fire & Rescue

Excellent Good Average Fair Poor
Additional comments or suggestions:
Contact Information (optional)
Do you wish to be contacted regarding this survey by the City of Manassas Fire and Rescue Department?

Yes No
Please verify that you are human *
Should be Empty: