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Resources / Questionnaire - Patient Satisfaction Survey


Please answer the questions below by placing a "check mark" in the appropriate box. If you don't understand any questions, please use the "I don't know" or "Not Applicable (NA)" option and move to the next question. If the question is not relevant to your experience, mark the 'NA' box and move on to the next question. Please note that your input will be kept confidential. Information obtained from you will be combined with the other responses and used for service improvement.

This survey is available in the following languages:
Spanish, Russan, Italian, Hatian-Creole, Korean, Mandarin, Arabic

Date of service enter as: M/D/YYYY

Time of service

Borough of Service

How did you learn about this questionnaire?
Community Event
3-1-1
Recent 9-1-1 Use
Internet search
Other

Who called 911?
I did
Family member
Friend/neighbor
Other

Which Ambulance arrived at your location?
FDNY
Hospital based
Community volunteer
Other
I don’t know

Was the ambulance crew polite and respectful?
Strongly agree
Agree
Disagree
Strongly disagree
Not applicable

Were you (or the patient) transported to the hospital of your choice?
Yes
No
I don’t know
Never went to the hospital

Did the ambulance crew understand and treat the illness/injury to your satisfaction?
Very satisfied
Satisfied
Neither satisfied, nor dissatisfied
Dissatisfied
Very Dissatisfied
I don’t know

How satisfied were you with our ability to communicate with you in the appropriate language?
Very satisfied
Satisfied
Neither satisfied, nor dissatisfied
Dissatisfied
Very Dissatisfied
I don’t know
Not applicable

Was a translation service utilized to facilitate communication?
Yes
No
I don’t know

How many times have you (the patient) used the 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

  

Please carefully review the information that you have entered before hitting the submit button. Please do not submit the same message more than once; doing so may delay processing.

 

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