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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.
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