Cleveland Clinic EMS Feedback Survey
We know your time is limited but your opinion is valuable to us. Please help us to improve by answering this short survey.
NO Patient information or HIPAA in this form please.
Which Cleveland Clinic Facility is this in reference to?
*
Please Select
Avon
Ashtabula
Brunswick
Euclid
Fairview
Hillcrest
Lakewood
Lodi
Lutheran
Main Campus - Cleveland Clinic
Marymount
Medina
Mentor
Mercy
South Pointe
Twinsburg
Union
Akron - Bath
Akron - Green
Akron - Main
Akron - Stow
What is your EMS agency?
*
Please rate your overall experience with your Cleveland Clinic Hospital today
1
2
3
4
5
Please rate your overall experience with the EMS Room today
1
2
3
4
5
How long was your wait time? Select the most accurate
Less than 10 Minutes
Between 10 - 30 Minutes
Between 31 - 60 Minutes
More than 1 hour
Any requests for the EMS room?
Drinks, Snacks, Equipment etc.
Any comments or concerns about your experience today?
For concerns about a specific event, please include identifying details such as names, dates, and times, so we may address the situation directly. NO HIPAA please.
When did this occur?
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
MM-DD-YYYY
Hour Minutes
If you would like to be contacted about this form please provide your email below
example@example.com
Submit
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