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2. Please rate the professionalism and appearance of the EMS crew

   1. Excellent
   2. Good
   3. Fair
   4. Poor
4. The EMS crew were competent, courteous, and displayed a genuine concern for my needs

   1. Strongly Agree
   2. Agree
   3. Disagree
   4. Strongly Disagree
6. The EMS crew appeared to be knowledgeable and answered my questions, and kept me informed

   1. Strongly Agree
   2. Agree
   3. Disagree
   4. Stronly Disagree
8. The EMS crew took time to explain the medical procedures to me, and also to my family

   1. Strongly Agree
   2. Agree
   3. Disagree
   4. Strongly Disagree
10. Overall satisfaction of the service you received

    1. Excellent
    2. Good
    3. Fair
    4. Poor
12. Were you taken to the hospital of your choice?

    1. Yes
    2. No
14. If “no” was it explained by the EMS crew as to why?

    1. Yes
    2. No
16. Would you like to be contacted?

    1. Yes
    2. No
18. If yes, please provide a name and contact number:
20. Please provide any additional comments:
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22. 1. Receive an email copy of this form.
23. Email address

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