2. AFR Medical Survey
4. AFR Personnel's Name (if known)
6. Date of Incident
7. Time of Incident
8. Incident # (if known)
10. Resident's Name (optional)
11. Resident's Phone # (optional)
13. Resident's Address (optional)
15. Prior to your most recent contact with AFR have you had any previous contact with this department?

    1. Yes

    1. No
17. How many contacts in the past 12 months?
19. In regards to your most recent incident, what was the nature of your contact?
    -- Select One --House FireRubbish FireBrush FireMotor Vehicle AccidentReported a ProblemRequested Information/AssistanceBurn PermitOther
21. Considering this most recent contact, please rate Andover Fire Rescue in the following areas:
23. AFR Appearance

    1. Excellent
    2. Good
    3. Fair
    4. Poor
24. AFR Professional Conduct

    1. Excellent
    2. Good
    3. Fair
    4. Poor
26. AFR Concern (Compassion)

    1. Excellent
    2. Good
    3. Fair
    4. Poor
27. AFR Ability to Put You at Ease

    1. Excellent
    2. Good
    3. Fair
    4. Poor
29. AFR Knowledge

    1. Excellent
    2. Good
    3. Fair
    4. Poor
30. AFR Response Time (if applicable)

    1. Excellent
    2. Good
    3. Fair
    4. Poor
32. AFR Helpfulness

    1. Excellent
    2. Good
    3. Fair
    4. Poor
33. AFR Appropriate Medical Care

    1. Excellent
    2. Good
    3. Fair
    4. Poor
35. Quality of AFR
37. In regards to this most recent contact, on a one to ten scale, please indicate your overall satisfaction with the AFR
    -- Select One --10 Excellent98 Good765 Fair43 Poor21 Very Poor
39. How can AFR improve the quality of its service in the future?
41. On a one to ten scale, please indicate how safe you feel living in the Andover community
    -- Select One --10 Very Safe98 Safe765 Fairly Safe43 Not Very Safe21 Very Unsafe
43. Would you like to leave any additional comments?

    1. Yes
    2. No
45. Additional Comments:
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

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