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Name of Facility
Date of Service
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Was Trinity staff on time?
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Yes
No
One a scale of 1-5 (1 being below average and 5 being excellent), Please rate Trinity’s performance in the following areas:
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The level of service provided by Trinity’s Dispatch personnel.
1
2
3
4
5
The general appearance of Trinity's personnel and uniforms.
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4
5
Trinity personnel’s behavior and demeanor towards the patient.
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2
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4
5
Trinity personnel’s behavior and demeanor towards staff members.
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2
3
4
5
The overall condition of the equipment.
1
2
3
4
5
Overall satisfaction with your entire Trinity experience.
1
2
3
4
5
Please provide any other comments you would like to share about your Trinity experience:
I grant permission for Trinity to use my comments for promotional purposes.
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Yes
No
Would you like a Trinity representative to follow-up with you regarding your experience?
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Yes
No
Please make sure you indciate the name of the facility and date of service above.