Picture Butte Emergency Services Feedback Form

Picture Butte Emergency Services Feedback Form
At Picture Butte Emergency Services, our committed Emergency Medical Services (EMS) team is dedicated to delivering outstanding patient care to those in need.

If you feel that you did not receive the level of attention or care you deserved, or if you believe the EMS personnel who assisted you should be acknowledged for their efforts in ensuring your well-being, please use this form to submit formal commendations or complaints regarding the service offered by Picture Butte Emergency Services.

We encourage you to share your feedback with us! Whether you have a compliment, concern, or suggestion, we invite you to take a moment to complete the survey below. Your insights are invaluable to improving our services.
- Name
  
  First NameLast Name
- Mailing Address:
- City/Town:
- Province:
- Telephone:
  Format: (000) 000-0000.
- Email:*
  example@example.com
- Date of Incident*
  
  MonthDayYear
  Date
- Where did your ambulance call occur?
- Who was the patient?
- Please indicate the patient's age range:
  
  Under 1818-3435-5455+
- Names of EMS Employee (if known):
- Approximate Time of Incident:
- Description of Incident:
- Did EMS personnel introduce themselves?
  
  YesNoNot Applicable
- How would you describe the ambulance response time (taking into consideration your location of the incident)?
  
  FastWithin reasonSlowUnsure
- How would you rate the courtesy of the EMS team?
  
  Extremely courteousModerately courteousNot at all courteousOther
- How would you rate the professionalism of the EMS team?
  
  Extremely professionalModerately professionalNot at all professionalOther
- How would you describe the cleanliness of the ambulance?
  
  Very clean/tidySomewhat clean/tidyDisorganized (visible clutter, lack of supplies etc.)Not applicable (I did not go in the ambulance)Other
- During your recent experience with the EMS team, did you notice any safety concerns for the patient, family member, friend, or EMS team?
  
  YesNoOther
- My feedback includes a:
  
  ComplaintCommendationSuggestionOther
- If you feel that you did not receive the attention or care you deserve, or if you feel the EMS personnel who attended to you deserve a commendation for taking extra steps to ensure your wellbeing, please let us know!
- Do you have any suggestions for improvement, comments, questions or concerns?
- How satisfied were you with your experience with our EMS team overall?
  
  Very satisfiedSatisfiedNeutralDissatisfiedVery dissatisfied
- Signature
- Date Form Submitted
  
  MonthDayYear
  Date
- Picture Butte Emergency Services
  
  120 - 4th Street North
  
  P.O. Box 670
  
  Picture Butte, AB T0K 1V0
  
  403-732-4100
  
  ambulance@picturebutte.ca
- Should be Empty: