Fire Department Customer Service Survey

We are sorry to have met you under such difficult circumstances, but we would be grateful to hear your thoughts on the service delivered by our team.

Click here to view form.

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Case Number
Date of Transport*
Date Format: MM slash DD slash YYYY
The County Board has authorized waiving transport fees when service is rendered (1) in connection with any natural or man-made disaster; (2) to an individual in Sheriff’s Department custody; and (3) to services at school or related activities for children under age 18. Also, any noncovered (insurance) ambulance service charges rendered while enrolled in Arlington County Housing Grants or Real Estate Tax Relief Programs are subject to reimbursement from the local Board of Public Welfare. Furthermore, a recipient with an annual household income of $25, 000 or less, special circumstances or in an Arlington County Department of Human Services program may request a transport fee waiver as well. All transport fee waivers are subject to the Fire Chief’s discretion.
Reason for request*
Information submitted through an Arlington County Government website is considered to be a Public Record under the Virginia Public Records Act and may be subject to release by the County in response to a request made under the Virginia Freedom of Information Act.

Do not submit any unsolicited personally identifiable information including (but not limited to) your: (1) social security number; (2) driver's license number; (3) bank account numbers; (4) credit or debit card numbers; (5) personal identification numbers (PIN); (6) electronic identification codes; (7) automated or electronic signatures; or (8) passwords; or (9) any other numbers or information that can be used to access your assets, obtain identification, act as identification, or obtain goods or services.

Arlington County may withhold your name and contact information in accordance with the Virginia Freedom of Information Act. Please indicate, by checking the box below, if you would like for the County to seek to keep this information confidential.
- Please do not disclose my name and contact information in response to a request under the Virginia Freedom of Information Act. I recognize that the County cannot guarantee the confidentiality of my name and contact information but ask that it do so to the extent permitted by law.
Comments
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