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2. Please take a few minutes to fill out and mail this survey back to us. We value you input and are striving to make improvements to provide the best quality of care. Thank you in advance.
   
   The following questions apply to the Torrington Ambulance Service:
4. 1) What was good about your experience of the ambulance service?
6. 2) What could improve about your experience of the ambulance service?
8. Please rate the following 5 questions, with 1 being very poor and 5 being very good.
10. 3) Overall rating of the ambulance service:

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
12. 4) How would you describe the overall cleanliness of the ambulance:

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
14. 5) The Medic who treated me:
16. 5a.) Provided care in a courteous and respectful manner:

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
18. 5b) Explained all medical procedures:

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
20. 5c) Was professional and knowledgeable:

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
22. 6) During the trip to the hospital:
24. 6a) I was made comfortable:

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
26. 6b) I felt safe:

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
28. 7) How would you rate the response time from when call was placed to the arrival of ambulance:

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
30. Please answer the following either "yes" or "no" and please explain when asked:
32. 8) Did you receive a bill for services?

    1. No
    2. Yes
34. 9) Was your insurance carrier billed for service provided?

    1. No
    2. Yes
36. 10) Do you feel the charges were fair for the service provided?

    1. No
    2. Yes
38. Please explain for "No" answer:
40. 11) Would you recommend this ambulance service to a friend or family?

    1. No
    2. Yes
42. Please explain for "No" answer:
44. 12) Have you ever visited the Torrington EMS website? (www.torringtonems.org)

    1. No
    2. Yes
46. 12a) If "no" to above question, is it because you do not know website address?

    1. No
    2. Yes
48. 12b) Is it due to not having internet access?

    1. No
    2. Yes
50. 13) Are there any crew member(s) that you would like to recognize?
52. 14) Additional Comments:
54. 15) Would you like to be contacted by the EMS Director about any of your responses in this survey?

    1. No
    2. Yes
56. Name
57. Email Address
59. Address
61. City
62. State
63. Zip Code
65. Phone Number
66. Fax Number
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68. 1. Receive an email copy of this form.
69. Email address

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70. Submit

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