Form Center

2. Franklin County Department of Public Safety • 1488 Franklin Street • Rocky Mount, VA 24151 • 540-483-3091
4. Choose the group that closest matches your age.*
   -- Select One --17 or younger18-2021-2930-3940-4950-5960 or older
5. What is your gender? (optional)

   1. Female
   2. Male
6. What is your race? (optional)
   -- Select One --WhiteBlack or African AmericanAmerican Indian or Alaskan NativeAsianNative Hawaiian or other Pacific IslanderMultiple Races
8. Where did you serve as a volunteer? (check all that apply)*

   1. Boones Mill Fire - EMS
   2. Burnt Chimney Fire Department
   3. Callaway Fire Department
   4. Callaway Rescue Squad
   5. Ferrum Fire Department
   6. Ferrum Rescue Squad

   1. Fork Mountain Fire Department
   2. Fork Mountain Rescue Squad
   3. Franklin County Public Safety Cadre
   4. Franklin County Rescue Squad
   5. Glade Hill Fire Department
   6. Glade Hill Rescue Squad

   1. Henry Fire Department
   2. Red Valley Rescue Squad
   3. Scruggs Fire - Rescue
   4. Snow Creek Fire Department
   5. Snow Creek Rescue Squad
10. In what capacity were you a volunteer in Franklin County?*

    1. Fire Suppression
    2. Emergency Medical Services
    3. Other
11. If other, please specify.
12. How long did you volunteer in Franklin County?*
    -- Select One --Less than 1 year1 - 3 years4 - 6 years7 - 10 years11 - 19 years20 - 29 years30 years or greater
13. In a typical month, about how many hours did you volunteer?*
15. Why did you initially decide to begin volunteering?*

    1. Help the community and others
    2. Increase my self-esteem
    3. Trying out a possible career
    4. Career Development

    1. Resume enhancement
    2. Develop new skills
    3. I wanted to do something I would enjoy
    4. Other
16. If other, please specify
18. Which of the following were important in influencing your decision to leave?*

    1. Lack of time
    2. Relocation/moving
    3. Family demands/changes
    4. Career or job demands/changes
    5. Financial hardship
    6. Issues with the organization
    7. Issues with career personnel
    8. Training requirements too stringent

    1. Too few training opportunities
    2. Uncomfortable atmosphere/environment
    3. Attitude of existing personnel
    4. Lack of support from existing members
    5. Lack of camaraderie/espirit de corps
    6. Not my decision to leave (e.g. termination, forced resignation, etc...)
    7. Other
19. If other, please specify
21. Overall, I rate the leadership of the station as:*

    1. Poor
    2. Fair
    3. Good
    4. Excellent
22. Overall, how satisfied were you with your volunteer experience with this organization?*

    1. Extremely dissatisfied
    2. Moderately dissatisfied
    3. Slightly dissatisfied
    4. Neither satisfied nor dissatisfied

    1. Slightly satisfied
    2. Moderately satisfied
    3. Extremely satisfied
24. How likely are you to recommend this organization to others as a place to volunteer?*

    1. Extremely likely
    2. Very likely
    3. Moderately likely
    4. Slightly likely
    5. Not at all likely
25. What incentives would have potentially helped you remain active as a volunteer?*

    1. Increased stipend
    2. Volunteer awards/recognition program
    3. Volunteer retirement system
    4. Reduced local taxes
    5. No incentives would have kept me volunteering
    6. Other
26. If other, please specify
28. What did you enjoy most about your role as a volunteer?
29. What did you enjoy least about your role as a volunteer?
31. Do you plan to volunteer with a fire or EMS agency again in the future?

    1. Yes
    2. No
    3. Maybe
32. I would like a representative from Human Resources to contact me to further discuss my volunteer experience.

    1. Yes
    2. No
36. Contact Info
    If you would like to be contacted, please provide your name and the preferred contact information.
38. Name
39. Email Address
41. Address
43. City
44. State
45. Zip Code
47. Phone Number
48. Cell Number
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field