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FIRE DEPARTMENT CUSTOMER SATISFACTION SURVEY

2. Date and approximate Time you encountered the Fire Department*
   Date and approximate Time you encountered the Fire Department

   Date and approximate Time you encountered the Fire Department

4. Name (Optional):

6. Location of Incident or Encounter (Optional):

8. Type of Incident or Encounter:*

   1. Fire
   2. Motor Vehicle Accident

   1. Medical Emergency

   1. Public Relations / Public Education

   1. Other ( Please Explain in Comments)

10. Please select the response that most accurately reflects your opinion for each statement.

    Please select the response that most accurately reflects your opinion for each statement.

12. The 911 Dispatcher was polite, helpful, and acted with a sense of urgency. *

    1. Strongly Agree
    2. Agree
    3. N/A
    4. Disagree
    5. Strongly Disagree

14. The Fire Department arrived in a reasonable amount of time.*

    1. Strongly Agree
    2. Agree
    3. N/A
    4. Disagree
    5. Strongly Disagree

16. The Fire Department Members presented themselves in a Professional and Respectful manner.*

    1. Strongly Agree
    2. Agree
    3. No feelings either
    4. Disagree
    5. Strongly Disagree

18. The Fire Department members addressed all my concerns or needs. *

    1. Strongly Agree
    2. Agree
    3. No feelings either
    4. Disagree
    5. Strongly Disagree

20. The Fire Department members ensured I was aware of their actions and informed me of what I should do next.*

    1. Strongly Agree
    2. Agree
    3. No feelings either
    4. Disagree
    5. Strongly Disagree

22. The Fire Department members ensured the situation was safe/ complete before leaving.*

    1. Strongly Agree
    2. Agree
    3. No feelings either
    4. Disagree
    5. Strongly Disagree

24. Any Additional Comments:

26. Optional Contact Information

28. Would you like a member of the Fire Department Command Staff to contact you?*

    1. Yes
    2. No

30. If you answered yes, please provide at least one of the next two.

32. Phone Number:

33. Email Address:

Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field