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* 1. What is the name of your agency?

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* 2. Is your agency EMS & Fire or a private ambulance company?

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* 3. What was the estimated date and time of your patient transport?

Date
Time

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* 4. To which Premier Emergency Department did you transport?

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* 5. What type of patient did you bring?

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* 6. If you provided a pre-arrival report to the ED, staff listened and acknowledged the information.

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* 7. On arrival I was greeted promptly and assigned a bed.

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* 8. When giving my bedside report, staff made eye contact and acknowledged the information.

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* 9. Staff was friendly, courteous and professional.

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* 10. I would feel comfortable approaching the physician on duty.

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* 11. The computers, internet, and printers were in good working order and met my needs.

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* 12. The EMS room was clean and stocked.

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* 13. I would recommend this hospital for

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* 14. I know which EMS coordinator to contact for education or follow up.

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* 15. The EMS coordinator is responsive to my needs.

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* 16. Are there any educational opportunities you would like Premier Health to provide?

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* 17. Is there anything Premier Health can do to improve care and service to you and your patients?

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* 18. Is there anyone you would like us to recognize for outstanding care?

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