• City of Tacoma QA
  • City of Tacoma OpenData




Feedback Form for EMS Services

  
Feedback Form for EMS Services

 

The feedback I am providing is: 

 Positive 

 Negative 

 

1. The level to which the personnel were polite and courteous was: 

 Excellent  

 Good  

 Fair  

 Poor  

 

2. The professionalism of the personnel that took care of me was: 

 Excellent  

 Good  

 Fair  

 Poor  

 

3. The promptness of the personnel that responded was: 

 Excellent  

 Good  

 Fair  

 Poor  

 

4. The knowledge and competence of the personnel were: 

 Excellent  

 Good  

 Fair  

 Poor  

 

5. The level to which the personnel took time to explain their actions was: 

 Excellent  

 Good  

 Fair  

 Poor  

 

6. My level of satisfaction with the service I received from the Fire Department at this incident is: 

 Excellent  

 Good  

 Fair  

 Poor  

 

7. In general, my level of satisfaction with the services provided by the Tacoma Fire Department is: 

 Excellent  

 Good  

 Fair  

 Poor 

 

 

 

If you WERE TRANSPORTED to a hospital, please skip this section and proceed directly to question 11.  

 

If you WERE NOT TRANSPORTED to the hospital:  

  

8. Were you offered transport to the hospital in a Medic Unit or ambulance?
 Yes
 No 

 

9. Did the personnel explain the risks of not being evaluated at a hospital to you?
 Yes  
 No 

   

10. After being treated by our personnel, were you hospitalized within the next 24 hours (not including the emergency department)?
 Yes  
 No   
  


11. Please enter your zip code for tracking purposes:  

  

   

  

The following information is optional: 

  

12. If any members of our staff were especially helpful, please let us know whom they were and how they were helpful. We want to show them our appreciation.  

Firefighter Names: 


 

Comments: 

 

  

 

Incident Information: 

  

Date of incident:  

 

Approximate Time:  

 

Location/Address:  

 

City:  

If other, please clarify in the "Comments" box above.  

 

 

Your Contact Information (Optional) 

 

First Name:   

 

Last Name:   

 

Street Address:   

 

City:     State:     Zip Code:   

 

Phone:   

 

Email:   

 

Confirm Email:   

 

Preferred method of contact:  Phone    Email  

 

Best time to contact you:  8 am - 12 pm      12 pm - 5 pm     5 pm - 9 pm 

  

 

Would you like to be contacted by a Fire Department representative? 

 Yes 

 No 

   

 



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