Pennie 26 Report Share Posted April 18, 2004 LIFE SATISFACTION SURVEY Resident Name: ____________________________ Room # ____________ Date: _____________ Surveyor: __________________________________ Does the facility help you be as independent as your health allows? Yes __ No ___ Comments: ____________________________________________________ Does the facility provide you quality medical care from your Dr when needed? Yes ______ No ______ Comments: _____________________________________________________ Do the employees treat you fairly without threat of mental or physical abuse? Yes __ No ___ Comments: ____________________________________________________ Do the employees appropriately help you with activities of daily living? Yes __ No ___ Comments: ____________________________________________________ Are the staff members open and friendly with the residents? Yes __ No ___ Comments: ____________________________________________________ Does the facility provide interesting activities, which involve you? Yes __ No ___ Comments: ____________________________________________________ Does the facility provide a nice room in an attractive setting? Yes __ No ___ Comments: ____________________________________________________ Does the facility provide good meals that meet your taste and dietary needs? Yes __ No ___ Comments: ____________________________________________________ Does the facility serve meals on time and in a timely manner? Yes __ No ___ Comments: ____________________________________________________ Does the facility help you feel safe and secure in your home? Yes __ No ___ Comments: ____________________________________________________ Does the facility help provide you with a compatible roommate? Yes __ No ___ Comments: ____________________________________________________ Does the facility help you to voice complaints and get results without reprisals? Yes __ No ___ Comments: ____________________________________________________ Does the facility help protect your individual right to privacy? Yes __ No ___ Comments: ____________________________________________________ Quote Link to comment Share on other sites More sharing options...
gina 2 Report Share Posted April 18, 2004 Thank you Pennie! :-) That is a great form. gina Quote Link to comment Share on other sites More sharing options...
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