Patient Survey

ROCK TOWNSHIP AMBULANCE DISTRICT ONLINE PATIENT SURVEY

We need to hear from you if you or a family member were treated and transported by the personnel of Rock Township Ambulance District.  As we strive to improve our services, your feedback is important to us. Your comments, both positive and negative, will be used to help educate our personnel on how they can improve their customer service.

Patient Name (required)

Your Email (required)

Date of Service (required)

R.T.A.D. Call # (required)

Recently you or a family member were treated and transported by the personnel of Rock Township Ambulance District. As we strive to improve our services, your feedback is important to us. Your comments, both positive and negative, will be used to help educate our personnel on how they can improve their customer service.

1. What time of day was your emergency?

2. Did the Ambulance arrive in a timely manner? Yes No 

3. Were the personnel polite, well groomed, and did they listen to your concerns? Yes No 

4. Did the personnel explain what they were doing and why certain treatments were needed?
Yes No 

5. Did the personnel appear confident in administering care? Yes No 

6. Did the personnel appear to be familiar with your condition? Yes No 

7. Were you taken to the hospital of your choice? Yes No 

If you answered no, please explain:

8. While in the back of the ambulance, did the equipment/ambulance seem clean and
tidy to you? Yes No 

9. How well did the personnel interact with family members on the scene, if applicable?

10. Did you need to contact our billing company with questions or concerns? Yes No 
If “yes”: Were the personnel polite? Yes No 
If “yes”: Were the personnel able to answer your questions? Yes No 

How would you rate, overall, your experience with Rock Township Ambulance District?
Very Poor Poor Fair/Adequate Good Very Good 

Other Comments

Would you like a representative from Rock Township Ambulance District to contact you regarding your comments? Yes No 
If Yes, Name:
Telephone Number: