Thank you for trusting us with your care. At Galveston Area Ambulance Authority, we are committed to providing high quality emergency medical services, and your feedback plays a vital role in helping us improve. Please take a few moments to complete this brief survey. 

1

Date of Service:

 *

mm/dd/yyyy

2

City:

 *

City:

---

Please rate the following aspects of your experience on a scale from 1 (Very Poor) to 5 (Excellent).

3

Response Time
How satisfied were you with the time it took for the ambulance to arrive?

Response Time How satisfied were you with the time it took for the ambulance to arrive?

	1 - Very Poor	2 - Poor	3 - Average	4 - Good	5 - Excellent
Rating:	Response Time How satisfied were you with the time it took for the ambulance to arrive?	Response Time How satisfied were you with the time it took for the ambulance to arrive?	Response Time How satisfied were you with the time it took for the ambulance to arrive?	Response Time How satisfied were you with the time it took for the ambulance to arrive?	Response Time How satisfied were you with the time it took for the ambulance to arrive?

4

Professionalism of Staff
How would you rate the courtesy and professionalism of the paramedics and EMTs?

Professionalism of Staff How would you rate the courtesy and professionalism of the paramedics and EMTs?

	1 - Very Poor	2 - Poor	3 - Average	4 - Good	5 - Excellent
Rating:	Professionalism of Staff How would you rate the courtesy and professionalism of the paramedics and EMTs?	Professionalism of Staff How would you rate the courtesy and professionalism of the paramedics and EMTs?	Professionalism of Staff How would you rate the courtesy and professionalism of the paramedics and EMTs?	Professionalism of Staff How would you rate the courtesy and professionalism of the paramedics and EMTs?	Professionalism of Staff How would you rate the courtesy and professionalism of the paramedics and EMTs?

5

Communication
Did the staff explain the procedures and treatments clearly?

Communication Did the staff explain the procedures and treatments clearly?

	1 - Very Poor	2 - Poor	3 - Average	4 - Good	5 - Excellent
Rating:	Communication Did the staff explain the procedures and treatments clearly?	Communication Did the staff explain the procedures and treatments clearly?	Communication Did the staff explain the procedures and treatments clearly?	Communication Did the staff explain the procedures and treatments clearly?	Communication Did the staff explain the procedures and treatments clearly?

6

Quality of Care
How satisfied were you with the medical care provided?

Quality of Care How satisfied were you with the medical care provided?

	1 - Very Poor	2 - Poor	3 - Average	4 - Good	5 - Excellent
Rating:	Quality of Care How satisfied were you with the medical care provided?	Quality of Care How satisfied were you with the medical care provided?	Quality of Care How satisfied were you with the medical care provided?	Quality of Care How satisfied were you with the medical care provided?	Quality of Care How satisfied were you with the medical care provided?

7

Comfort and Safety
Did you feel safe and comfortable during your transport?

Comfort and Safety Did you feel safe and comfortable during your transport?

	1 - Very Poor	2 - Poor	3 - Average	4 - Good	5 - Excellent
Rating:	Comfort and Safety Did you feel safe and comfortable during your transport?	Comfort and Safety Did you feel safe and comfortable during your transport?	Comfort and Safety Did you feel safe and comfortable during your transport?	Comfort and Safety Did you feel safe and comfortable during your transport?	Comfort and Safety Did you feel safe and comfortable during your transport?

8

Cleanliness
How would you rate the cleanliness of the ambulance and equipment?

Cleanliness How would you rate the cleanliness of the ambulance and equipment?

	1 - Very Poor	2 - Poor	3 - Average	4 - Good	5 - Excellent
Rating:	Cleanliness How would you rate the cleanliness of the ambulance and equipment?	Cleanliness How would you rate the cleanliness of the ambulance and equipment?	Cleanliness How would you rate the cleanliness of the ambulance and equipment?	Cleanliness How would you rate the cleanliness of the ambulance and equipment?	Cleanliness How would you rate the cleanliness of the ambulance and equipment?

---

Additional Feedback

9

Were there any challenges or concerns during your experience?

Were there any challenges or concerns during your experience?

10

What did you appreciate most about our service?

What did you appreciate most about our service?

11

What can we do to improve?

What can we do to improve?

12

Would you recommend the Galveston Area Ambulance Authority to others?

Would you recommend the Galveston Area Ambulance Authority to others?

Yes

No

Unsure

---

13

If you would like to speak with a member of our staff about any concerns you encountered during your experience, please provide your name and contact information below. We value your feedback and are here to assist you.

If you would like to speak with a member of our staff about any concerns you encountered during your experience, please provide your name and contact information below. We value your feedback and are here to assist you.

Name:

Email:

Phone Number:

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

Page 1 / 1