Jefferson County Ambulance Service strives to provide the best possible pre-hospital care. We take pride in ensuring each and every person is treated with courtesy, compassion and with the latest advancements in pre-hospital, emergency care. To deliver the highest quality standard of care we need your feedback. Please take a few moments to complete this survey. Your honest evaluation helps to improve our service delivery and quality.

Date of Service:*

Were you transported by EMS?*

Yes

No

Were you admitted to the Hospital?*

Yes

No

Please complete the evaluation below:

Service

Courtesy of the Crew:*

Excellent Good

Fair Poor

Appearance of the Crew:*

Excellent Good

Fair Poor

Promptness of Service:*

Excellent Good

Fair Poor

Explanation of Services:*

Excellent Good

Fair Poor

Personal Concern:*

Excellent Good

Fair Poor

Professionalism:*

Excellent Good

Fair Poor

Comments or Recommendations:

The Ambulance

Cleanliness:

Excellent Good

Fair Poor

Comfortable Temperature:

Excellent Good

Fair Poor

Ride to Hospital:

Excellent Good

Fair Poor

Comments or Recommendations:

The Office Staff

Courteous:

Excellent Good

Fair Poor

Helpful:

Excellent Good

Fair Poor

Comments or Recommendations:

Overall Impression of Jefferson County EMS

Overall Care:*

Excellent Good

Fair Poor

Overall Experience:*

Excellent Good

Fair Poor

Comments or Recommendations:

Name:

Phone Number: 000-000-0000

Thank you for taking the time to complete this questionnaire. If you would like to speak with someone or have a question, contact James Tweed at (785)403-0166.