VCHCA - VCEMSA Questionnaire - Medical Satisfaction

Emergency Medical Services

Medical Services Questionnaire

Please complete the survey and click "Submit" to transmit. If you are not able to E-mail directly, complete the survey, print it on your local printer, and mail to the address located at the end of the page.

This survey is limited to service provided by Emergency Medical Service Providers in Ventura County. The information you provide on this questionnaire will be used to improve service. It is not necessary to indicate your name.

Date of Service: Time of Service:

Service Provider(i.e., ambulance, helicopter, hospital):

1. Location of service:

2. Comments:

3. How would you rate the Service Provider's performance?

Excellent Good Average Poor

If you would like a response to your comments, please complete the information below:

Name:

Address:

City, State, Zip:

Daytime Number:

Ventura County Public Health
Emergency Medical Services
Attn: Administrator
2220 E. Gonzales Road, Suite 130
Oxnard, CA 93036-0619