Patient Satisfaction Survey

Please tell us about your experience with Manatee County EMS. We are committed to providing quality care and service. Thank You!

Q1	Service Information
	Billing Account # or Patient Name

	Date of Service

	Contact Name/Number/email (Optional)

Q2	Response
Q2		Exceeded Expectations		Met Expectations		Below Expectations		Not Applicable
	Response was timely	Response was timely Exceeded Expectations		Response was timely Met Expectations		Response was timely Below Expectations		Response was timely Not Applicable

	Ability to locate you/your address	Ability to locate you/your address Exceeded Expectations		Ability to locate you/your address Met Expectations		Ability to locate you/your address Below Expectations		Ability to locate you/your address Not Applicable

Q3	Paramedics/EMT
Q3		Exceeded Expectations		Met Expectations		Below Expectations		Not Applicable
	Professionalism of the crew	Professionalism of the crew Exceeded Expectations		Professionalism of the crew Met Expectations		Professionalism of the crew Below Expectations		Professionalism of the crew Not Applicable

	Care for you as a person	Care for you as a person Exceeded Expectations		Care for you as a person Met Expectations		Care for you as a person Below Expectations		Care for you as a person Not Applicable

	Information provided about your care	Information provided about your care Exceeded Expectations		Information provided about your care Met Expectations		Information provided about your care Below Expectations		Information provided about your care Not Applicable

	Appearance of staff	Appearance of staff Exceeded Expectations		Appearance of staff Met Expectations		Appearance of staff Below Expectations		Appearance of staff Not Applicable

Q4	Ambulance
Q4		Exceeded Expectations		Met Expectations		Below Expectations		Not Applicable
	Parking and proximity to you	Parking and proximity to you Exceeded Expectations		Parking and proximity to you Met Expectations		Parking and proximity to you Below Expectations		Parking and proximity to you Not Applicable

	Cleanliness of ambulance and equipment	Cleanliness of ambulance and equipment Exceeded Expectations		Cleanliness of ambulance and equipment Met Expectations		Cleanliness of ambulance and equipment Below Expectations		Cleanliness of ambulance and equipment Not Applicable

	Comfort of the ride	Comfort of the ride Exceeded Expectations		Comfort of the ride Met Expectations		Comfort of the ride Below Expectations		Comfort of the ride Not Applicable

Q5	Office Staff / Billing Company
Q5		Exceeded Expectations		Met Expectations		Below Expectations		Not Applicable
	Professionalism of the office staff	Professionalism of the office staff Exceeded Expectations		Professionalism of the office staff Met Expectations		Professionalism of the office staff Below Expectations		Professionalism of the office staff Not Applicable

	Professionalism of the billing company (AMB)	Professionalism of the billing company (AMB) Exceeded Expectations		Professionalism of the billing company (AMB) Met Expectations		Professionalism of the billing company (AMB) Below Expectations		Professionalism of the billing company (AMB) Not Applicable

	Willingness to address your needs	Willingness to address your needs Exceeded Expectations		Willingness to address your needs Met Expectations		Willingness to address your needs Below Expectations		Willingness to address your needs Not Applicable

Q6	Overall Assessment
Q6		Exceeds Expectations		Met Expectations		Below Expectations
	Our staff worked together for you	Our staff worked together for you Exceeds Expectations		Our staff worked together for you Met Expectations		Our staff worked together for you Below Expectations

	Overall rating of the care provided	Overall rating of the care provided Exceeds Expectations		Overall rating of the care provided Met Expectations		Overall rating of the care provided Below Expectations

Q7	Additional Information
	Please provide additional comments for any responses of Exceeds or Below Expectations

	If any member stood out, please let us know so we can share your thoughts with them