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NKF&R Service Delivery Survey

Date of Service:

Incident Number:

Type of Service: Emergency medicalFireOther emergency serviceNon-emergency service

Please describe non-fire or non-emergency medical service:

Please answer the following questions on a rating scale of 1 to 5. 1 = Unable to Rate, 2 = Poor, 3 = Fair, 4 = Good, 5 = Excellent

Was your request for assistance handled efficiently, courteously and without confusion? 12345

Did help arrive within an acceptable time frame? 12345

Did our personnel seem courteous and caring?  Did they treat you and your family with respect? 12345

Did our personnel perform all of the actions you felt were necessary? 12345

Did our personnel explain what they did or were going to do for you? 12345

Did our personnel explain what they did or were going to do for you? 12345

If you would like to further comment on any of the above questions please do so here:

Do you have any questions about the department or the services you received?:

Special comments:

Thank you for taking the time to complete this form.