Crivitz Rescue Squad, Inc.

Patient Care Survey

Crivitz Rescue is currently conducting a patient care survey in an effort to collect feedback and improve the service that we provide to the Crivitz-area communities.  We would greatly appreciate you completing this short survey and providing us with your comments.

Entering your name and date of service allows us to address specific 911 calls and provide feedback to the  crewmembers who where on your call.  Personal information will be kept on a need-to-know basis and will only be used for in-house quality improvement.

Full Name: (Requested)

Date of Service:  The date that you were transported by Crivitz Rescue   (Requested)

Email Address:
Check here to be contacted with follow up information.


Timeliness of Response
Crew Appearance
Cleanliness of Ambulance
Crew Professionalism
Crew Interaction with Patient
Crew Interaction with Family
Overall Care Received


Question 1:
Did the ambulance crew listen carefully?

Question 2:
Did the ambulance crew ask about your previous medical history?

Question 3:
Did you have trust and confidence in the ambulance crew's professional skills?

Question 4:
Were the ambulance crew reassuring?

Question 5:
Did the ambulance crew explain your care and treatment in a way you could understand?

Question 6:
Did the ambulance crew show you the respect that you would expect to receive?

Question 7:
Did the ambulance crew do everything they could to help control your pain?

Question 8:
If friends or relatives were with you, were they given enough information?

Question 9:
Was the way you got into the ambulance suitable (e.g. by walking, on a stretcher etc?)

Question 10:
Overall, did the ambulance crew treat you with respect and dignity

Additional Comments: