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DEAR:  ______________                         DOB:___________________
Thank you for allowing us to provide care for you and your family member. We are interested in your ideas or opinions about out care/services. Please take a moment to answer the following questions. Additional comments are welcome and can be recorded on the back of this form. If you need assistance in completing this form, feel free to contact our office.

      For questions 1-10, please circle the appropriate number that best describes your opinion.
  1-Strongly Agree       2-Agree       3-Disagree       4-Strongly Disagree       5-No Opinion or Not Applicable

  1. I was satisfied with the care provided by the:
  2. Nurse

 

1           2          3          4          5

  1. Physical Therapy

1           2          3           4          5

  1. Occupational Therapy

1           2          3          4          5

  1. Speech/Language Pathologist

1           2         3            4           5

  1. Medical Social Worker

1           2         3           4             5

  1. Home Health Aide (s)

1           2         3          4             5

  1. I was involved in decision-making regarding my plan of care. 

1          2          3         4           5

  1. My opinions were considered in the planning for discharge.

1           2         3          4          5

  1. Staff treated me, my family, my home and belongings with respect.

1           2         3          4          5

  1. Staff explained my conditions, rights and responsibilities, and other procedures related to the care I received.

1           2         3          4          5

  1. The staff generally arrived as schedule.

1           2         3          4         5

  1. I was able to reach my nurse/therapist promptly and my phone calls were returned.

1           2         3          4         5

  1. When I called the agency, office staff was courteous and available and directed my call correctly.

1           2         3          4         5

  1. I would use this agency again.

1           2         3          4         5

  1. I would recommend this agency to friends and relatives.

1           2         3          4         5

  1. Suggestions for improvements/additional comments:

A._______________________________________________________________________
B.________________________________________________________________________
C.________________________________________________________________________

  1. What most impressed me about the agency’s care/service was:

A._______________________________________________________________________
B._______________________________________________________________________
C._______________________________________________________________________

Thank you for your valuable feedback. This confidential information will be used only in efforts to improve care/service.
Sincerely,
__________________________________________
Organization Director or Administrator Signature
               

I __would/_____would not like to discuss my Responses further.
Please return the completed questionnaire in the enclosed, self-addressed, stamp envelope.

____________________________________________     ____/___/____
Optional Signature of Person Completing Form        Date