* Required Fields are empty
 
SATISFACTION QUESTIONNAIRE
Mail Survey Phone Survey
 

* Name   * Date  
 

Thank you for allowing us to provide care for you or your family member. 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 - Strongly Agree   2 - Agree    3 - Disagree   4 - Strongly Disagree   5 - No Opinion   6 - Not Applicable


1. I was satisfied with the care provided by the:
      a. Nurse(s) 1 2 3 4 5 NA
      b. Physical Therapist 1 2 3 4 5 NA
      c. Occupational Therapist 1 2 3 4 5 NA
      d. Speech/Language Pathologist 1 2 3 4 5 NA
      e. Medical Social Worker 1 2 3 4 5 NA
      f. Home Health Aides(s) 1 2 3 4 5 NA
 
2. Staff explained the care/services to be provided and the expected outcomes of care. 1 2 3 4 5 NA
 
3. I was involved in the decision-making process about my plan of care from admission through discharge. 1 2 3 4 5 NA
 
4. Staff treated me, my family, my home and belongings with respect. 1 2 3 4 5 NA
 
5. Staff explained my conditions, rights and responsibilities, and other procedures related to the care I received. 1 2 3 4 5 NA
 
6. Staff assisted me with managing my pain and discomfort. 1 2 3 4 5 NA
 
7. The staff generally arrived as scheduled. 1 2 3 4 5 NA
 
8. When I called the agency, office staffs were courteous and available and directed my call correctly. 1 2 3 4 5 NA
 
9. I would use this agency again. 1 2 3 4 5 NA
 
10. I would recommend this agency to friends and relatives. 1 2 3 4 5 NA
 
11. Suggestions for improvements/additional comments:
 
12. What most impressed me about the agency's care/service was:

Thank you for your valuable feedback. This confidential information will be used only in efforts to improve care/service. Sincerely       I would / would not like to discuss my      responses further.
     Please return the completed questionnaire in the      enclosed, self-addressed, stamped envelope.
 
 
     
      Office Manager or Administrator Signature Optional Signature of Person Completing Form               Date