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Date: December 04, 2022
Thank you for allowing us to provide care for you or your family members. We are interested in your ideas or opinions about our 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, please feel free to contact our office.
For questions 1 - 10, please circle the appropriate number that best describes your opinion. 1- Strong Agree , 2 - Agree , 3 - Disagree , 4 - Strongly Disagree , 5 - No Opinion
1. I was satisfied with the care provided by the:
a. Nurse(s) 12345
b. Physical Therapist 12345
c. Occupational Therapist 12345
d. Speech/Language Pathologist 12345
e. Medical Social Worker 12345
f. Home Health Aide(s) 12345
2. Staff explained the care/services to be provided and the expected outcomes of care.
12345
3. I was involved in the decision-making process about my plan of care from admission through discharge.
12345
4. Staff treated me, my family, my home and belongings with respect.
12345
5. Staff explained my conditions, rights and responsibilities, and other procedures related to the care I received.
12345
6. Staff assisted me with managing my pain and discomfort.
12345
7. The Staff generally arrived as scheduled.
12345
8. When I called the agency, office staff were courteous and available and directed my call correctly.
12345
9. I would use this agency again.
12345
10. I would recommend this agency to friends and relatives.
12345
11. Suggestions for improvements/ additional comments:  
12. What most impressed me about the agency's care/service was:

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