Date of Service: Time of Day:  Day of Week: example: 4/5/2008 example: 12:01 am -Select Day Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Customer Service for the 911 Center (Telecommunicator)
	Very Poor	Poor	Fair	Good	Very Good	N/A
The (911) Telecommunicator's ability to provide helpful information:
Level of courtesy of (911) Telecommunicator:
The (911) Telecommunicator's ability to treat caller with respect and dignity:
Customer Service for the EMS System
	Very Poor	Poor	Fair	Good	Very Good	N/A
Uniform Appearance:
Cleanliness of Ambulance and Equipment:
Paramedic / EMT ability to treat family / friends with respect and dignity:
Courtesy of Paramedics / EMTs to patient:
Paramedic's / EMT's concern about keeping you informed:
Technical Skill of Paramedics / EMTs:
Overall Customer Service Satisfaction with E-911 and EMS:
Comments: