🏥 St. Raphael Medical Center, Inc.
Mabalacat City, Pampanga | CONFIDENTIAL
📋 Ambulance Service Survey
← Back to Survey Selection
Instructions / Panuto:
Kindly place a check (✓) on your choice based on your experience.
Pakilagyan po ng tsek (✓) ang inyong piniling kasagutan ayon sa inyong karanasan sa SRMCI.
Rating Scale:
5
– Excellent (Napakahusay)
4
– Very Good (Mas Mainam)
3
– Good (Mainam)
2
– Fair (Pangkaraniwan)
1
– Poor (Kailangan Pagbutihin)
Dispatch (Ipinadala)
Professionalism of person on the phone.
*
Propesyonalismo ng tao sa telepono.
5
Excellent
4
Very Good
3
Good
2
Fair
1
Poor
Ability of person on phone to meet dispatch help.
*
Kakayahan ng tao sa telepono na matugunan ang ipinadalang tulong.
5
Excellent
4
Very Good
3
Good
2
Fair
1
Poor
Speed in which person on the phone dispatched help.
*
Bilis nung tao sa telepono sa pagpadala ng tulong.
5
Excellent
4
Very Good
3
Good
2
Fair
1
Poor
Information given prior to ambulance arrival.
*
Pagbibigay ng impormasyon bago dumating ang ambulansya.
5
Excellent
4
Very Good
3
Good
2
Fair
1
Poor
Ambulance driver's care while driving to make the journey comfortable as possible.
*
Pag-iingat ng driver para gawing komportable ang paglalakbay.
5
Excellent
4
Very Good
3
Good
2
Fair
1
Poor
Communications (Kumunikasyon)
Ambulance staff's concern for your privacy.
*
Pag-aalala ng tauhan ng ambulansya sa iyong privacy.
5
Excellent
4
Very Good
3
Good
2
Fair
1
Poor
Degree to which the ambulance staff took your condition seriously.
*
Antas ng pagbigay halaga sa iyong kondisyon ng tauhan ng ambulansya.
5
Excellent
4
Very Good
3
Good
2
Fair
1
Poor
Ambulance staff's efforts to inform you about treatment.
*
Pagsisikap ng tauhan ng ambulansya na ipaalam sa iyo ang tamang paggamot.
5
Excellent
4
Very Good
3
Good
2
Fair
1
Poor
Degree to which the ambulance staff worked together to care for you.
*
Antas ng pagtutulungan ng mga tauhan para sa pag-aalaga sa iyo.
5
Excellent
4
Very Good
3
Good
2
Fair
1
Poor
Overall Rating
Overall, how would you rate the care you received from our ambulance service?
*
Sa kabuuan, ano ang antas ng pangangalagang natanggap mo sa aming serbisyong pang-ambulansya?
5
Excellent
4
Very Good
3
Good
2
Fair
1
Poor
Person completing this form is the patient:
*
✅ Yes (Oo)
❌ No (Hindi)
Comments
Additional Comments:
*
📋 Patient / Informant Information
(Mga Pagkakakilanlan)
Patient's Name
(Pangalan ng Pasyente)
Informant's Name
(Pangalan ng Nagpahayag)
Age
(Edad)
Room No.
(Silid)
Contact No.
Date Admitted
(Petsa ng Pag-admit)
Date Discharged
(Petsa ng Paglabas)
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