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Date of Application:
(mm/dd/yyyy)
Client Name
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Last
First
Middle
Thank you for allowing us to provide care for you or your family member. We are interested in your ideas or options about our care/services. Please take a moment to answer the following questions.
For questions 1-10, please select 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:
a. Nurse(s)
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b. Physical Therapist
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c. Occupational Therapist
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d. Speech/Language Pathologist
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e. Medical Social Worker
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f. Home Health Aide(s)
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2. Staff explained the care/services to be provided and the expected outcomes of care.
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3. I was involved in the decision-making process about my plan of care from admission through discharge.
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4. Staff treated me, my family, my home and belongings with respect.
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5. Staff explained my conditions, rights and responsibilities, and other procedures related to the care I received.
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6. Staff assisted me with managing my pain and discomfort.
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7. The staff generally arrived as scheduled.
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8. When I called the agency, office staff were courteous and available and directed my call correctly.
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9. I would use this agency again.
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10. I would recommend this agency to friends and relatives.
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11. Suggestions for improvements/additional comments:
12. What most impressed me about the agency's care/service was:
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