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2. Select Department:*

   1. Fire Department
   2. Emergency Medical Services
   3. Fire Prevention/Code Enforcement
3. Is this a:*

   1. Compliment
   2. Complaint
5. Is this a Commercial Occupancy?*

   1. Yes
   2. No
6. Is this a Multi-Family or Apartment Building?*

   1. Yes
   2. No
8. What is the address?*
10. How would you rate the response time of the ambulance when you called 911?*

    1. Excellent
    2. Good
    3. Fair
    4. Poor
11. Did the EMTs arrive prepared with the proper medical equipment and supplies?

    1. Yes
    2. No
13. Were the EMTs professional, courteous, and competent in providing medical care?

    1. Yes
    2. No
14. Did the EMTs effectively communicate with you about the patient's condition and next steps?

    1. Yes
    2. No
16. Were you satisfied overall with the quality of care provided by the EMTs?

    1. Yes
    2. No
18. Do you have any additional comments or suggestions on how to improve the EMS services provided?
20. Please submit feedback.*
22. Your Contact Information
24. Name*
26. Address
28. City
29. State
31. Phone Number*
32. Email Address
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34. 1. Receive an email copy of this form.
35. Email address

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36. Submit

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