© 2013 Berlin Area Ambulance Assoc.

Background Information
Please tell us the date of service:
Patient age:
Patient gender:
Are you the patient?
If NO, what is your relationship to the patient?
Was your experience due to a 911 call?
Why did you need medical assistance?
(Enter the generic nature of your emergency)
Service Delivery
Poor              Fair          Good          Excellent
How would you rate the ambulance response time?

How would you rate the quality of medical care that you received?
How would your rate the degree to which the crew listened to your concerns?
How would you rate the the degree to which the crew explained the procedures they performed in a way that you could understand?
How would you rate the overall attitude and appearance of the crew?
How would you rate the cleanliness of the ambulance and equipment?
How would you rate your overall satisfaction with the service you received?
Additional Comments
What was the single most important action we took that
made you feel better or helped improve your situation?

What could we have done differently that might have made your experience more positive?

Were any members of our staff especially helpful? If so please include their name
(or physical description if name unknown) and describe their noteworthy actions.

Is there anything else that you would like to tell us about your experience?

Contact Information
Would you like someone from Berlin Area Ambulance Assoc. Inc. to contact you in response to comments or concerns you’ve mentioned in this survey?

Yes                                  No

If YES, please provide the following information:
Phone Number:
Email Address:
Preferred method of contact:          Phone          Email   

Berlin Area Ambulance Assoc. Inc. is committed to providing the best quality care to the citizens of our community during their time of need.  In order that we may continue to provide the type of emergency care that you deserve we ask for your opinion and suggestions in the following survey.  Thank you for taking the time to help us be the best that we can be for Berlin and the surrounding communities.


Please fill out the survey pertaining to your most recent experience with Berlin Area Ambulance Assoc. Inc.