Title Page
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Document No.
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PTS CUSTOMER SATISFACTION SURVEY
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WHAT IS YOUR VEHICLE CALL SIGN?
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Conducted on
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CREW PIN(S) OF CREW BEING SURVEYED
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Location
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PLEASE HAND THE PAD TO THE PERSON COMPLETING THE SURVEY - PLEASE ASSIST THE PERSON SHOULD THE REQUIRE IT!
WHO IS BEING SURVEYED
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THANK YOU FOR TAKING THE TIME TO FILL OUT THIS PATIENT SATISFACTION SURVEY
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MAY WE HAVE YOUR NAME ?
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PLEASE ENTER YOUR NAME
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SOME DETAILS ABOUT YOU ?
- AGE LESS THAN 18
- BETWEEN 18-30
- BETWEEN 31-50
- BETWEEN 51-65
- BETWEEN 66-80
- GREATER THAN 80
- DECLINE TO GIVE MY AGE
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WHAT KIND OF SERVICE USER ARE YOU ?
- WALKING PATIENT
- WHEELCHAIR PATIENT
- STRETCHER PATIENT
- GUARDIAN / RELATIVE
- CLINICAL STAFF
- MANAGER
- OTHER
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PLEASE PROVIDE MORE DETAILS ABOUT YOURSELF. THANK YOU.
SURVEY
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WERE THE CREW PROMPT?
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HOW WOULD YOU RATE THE PROFESSIONALISM OF THE AMBULANCE CREW?
- EXCELLENT
- GOOD
- ADEQUATE
- POOR
- UNACCEPTABLE
- NOT APPLICABLE
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HOW WOULD YOU RATE THE AMBULANCE CREWS ABILITY TO WHAT THEY WERE DOING AND WHY?
- EXCELLENT
- GOOD
- ADEQUATE
- POOR
- UNACCEPTABLE
- NOT APPLICABLE
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HOW WOULD YOU RATE THE LEVEL OF REASSURANCE YOU RECIEVED FROM THE AMBULANCE CREW?
- EXCELLENT
- GOOD
- ADEQUATE
- POOR
- UNACCEPTABLE
- NOT APPLICABLE
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HOW DO YOU FEEL THOSE ACCOMPANYING YOU WERE TREATED?
- EXCELLENT
- GOOD
- ADEQUATE
- POOR
- UNACCEPTABLE
- NOT APPLICABLE
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WOULD YOU USE THIS SERVICE AGAIN?
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WOULD YOU CARE TO MAKE ANY COMMENTS WHICH MAY HELP TO IMPROVE THE SERVICE?
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THANK YOU FOR TAKING THE TIME TO COMPLETE THIS SURVEY.
