The Valparaiso Fire Department strives to provide excellent patient care & service to the citizens and guests we serve. Please take a moment to complete this short patient satisfaction survey to help us better serve our community.

What was the date of service?*

How would you rate our response time?*

Excellent Good Adequate

Poor Unacceptable

How would you rate the professionalism of our EMT's & paramedics?*

Excellent Good Adequate

Poor Unacceptable

How would you rate the appearance and cleanlieness of our ambulance / equipment?*

Excellent Good Adequate

Poor Unacceptable

How would you rate the ambulance crew's ability to explain the care & interventions they were providing to you?*

Excellent Good Adequate

Poor Unacceptable

How would you rate the ambulance crew's response to your needs?*

Excellent Good Adequate

Poor Unacceptable

How would you rate the ambulance crew's interaction with your family and/or friends?*

Excellent Good Adequate

Poor Unacceptable

How confident are you in requesting our services again in the future?*

Very Confident Confident Somewhat Confident

Not Confident Not At All Confident

How would you rate your overall experience with the Valparaiso Fire Department?*

Excellent Good Adequate

Poor Unacceptable

Please provide us with any additional comments you have.

If you would like someone to contact you, please provide us with the following information:

First & Last Name:

Are you the patient or legal guardian of the patient?

Yes

No

Telephone Number:

E-mail Address (optional):