Patient Feedback Form Putnam County, Ohio - EMS Patient Feedback Form Thank you for taking the time to provide feedback regarding the emergency medical services (EMS) care you or a family member received. Your responses help us evaluate performance, improve patient care, and enhance community trust. This form is confidential and used for quality improvement purposes. Call Information (Optional) Date of EMS Response Approximate Time of Response: 121234567891011 : 00153045 AMPM Location of Incident (City/Township): Patient Age Range: Under 1818-2930-4445-6465+ EMS Crew Professionalism EMS Crew Professionalism * Courtesy & professionalism of EMS personnel * 5 (Excellent) 4 3 2 1 (Very Poor) EMS personnel treated the patient with dignity & respect * 5 (Excellent) 4 3 2 1 (Very Poor) EMS personnel appeared knowledge a ble & competent * 5 (Excellent) 4 3 2 1 (Very Poor) EMS personnel worked well Item as a team * 5 (Excellent) 4 3 2 1 (Very Poor) Care & Treatment Care & Treatment * Assessment of the patient's condition * 5 (Excellent) 4 3 2 1 (Very Poor) Explanation of care, procedures, or medications * 5 (Excellent) 4 3 2 1 (Very Poor) Pain management & comfort measures * 5 (Excellent) 4 3 2 1 (Very Poor) Overall confidence in the care provided * 5 (Excellent) 4 3 2 1 (Very Poor) Communication & Safety Communication & Safety * I felt the EMS crew listened to my concerns. * Strongly Agree Agree Neutral Disagree Strongly Disagree The EMS crew explained what was happening in a way I could understand. * Strongly Agree Agree Neutral Disagree Strongly Disagree I felt safe during the EMS response and transport (if applicable). * Strongly Agree Agree Neutral Disagree Strongly Disagree Transport Experience (If Applicable) Transport Experience (If Applicable) * Care during ambulance transport. * 5 (Excellent) 4 3 2 1 (Very Poor) Comfort and cleanliness of the ambulance. * 5 (Excellent) 4 3 2 1 (Very Poor) Communication with hospital staff during hand-off. * 5 (Excellent) 4 3 2 1 (Very Poor) What Went Well Please tell us what the EMS crew did well: Opportunities for Improvement Please tell us how we could improve our EMS services: Overall Satisfaction Transport Experience (If Applicable) Overall, how satisfied were you with the EMS care provided? Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied Would you recommend our EMS services to others in an emergency? * Yes No Unsure Would you recommend our EMS services to others in an emergency? * Yes No Unsure Follow-Up (Optional) If you would like to be contacted regarding your feedback, please provide your information below: Name Name First Name First Name Last Name Last Name Phone Email Thank you for helping us improve emergency medical services in our community. Captcha Submit If you are human, leave this field blank.
