* Required Information

As part of our continuous improvement and ongoing effort to improve the quality of services and care our facility delivers, we are providing you the opportunity to complete an evaluation of your level of satisfaction with our services.

This satisfaction evaluation will be maintained in resident’s record.

Name – Resident *

Date Form Completed *

List any other services you receive that are not included in the above list:

List other services or activities that you feel you need but are NOT provided or arranged by the AFH.

2. Overall, I am satisfied with the services provided by this facility 4

Yes	Somewhat
No	Don't Know

Comments

3. The care I receive is the kind of care I desire.

Yes	Somewhat
No	Don't Know

Comments

4. The facility meets my treatment preferences (choice of doctors, pharmacy, etc.)

Yes	Somewhat
No	Don't Know

Comments

5. The facility meets my preferences for services (I receive the services I need or want).

Yes	Somewhat
No	Don't Know

Comments

6. The facility offers a variety of activities for me to choose from.

Yes	Somewhat
No	Don't Know

Comments

is always enough

Yes	Somewhat
No	Don't Know

Comments

is of a wide variety

Yes	Somewhat
No	Don't Know

Comments

hot foods are served hot and cold foods are served cold

Yes	Somewhat
No	Don't Know

Comments

List activities in which you take part and how often you participate.

List any activities you would like to have but which are not available.

7. There appears to be enough staff on duty at all times to meet my needs as well as those of other residents.

Yes	Somewhat
No	Don't Know

Comments

8.Staff members appear to know what their responsibilities are.

Yes	Somewhat
No	Don't Know

Comments

9. I am treated respectfully at all times.

Yes	Somewhat
No	Don't Know

Comments

10. My rights have been explained to me.

Yes	Somewhat
No	Don't Know

Comments

11. I feel that my rights are being protected.

Yes	Somewhat
No	Don't Know

Comments

12. The food served

Yes	Somewhat
No	Don't Know

Comments

is of good quality

Yes	Somewhat
No	Don't Know

Comments

meets my nutritional needs

Yes	Somewhat
No	Don't Know

Comments

is prepared well

Yes	Somewhat
No	Don't Know

Comments

tastes good

Yes	Somewhat
No	Don't Know

Comments

13. My room is comfortable and meets my needs.

Yes	Somewhat
No	Don't Know

Comments

14. The furnishings in my room are kept in good repair.

Yes	Somewhat
No	Don't Know

Comments

15. My room, as well as the rest of the facility, is kept neat and clean.

Yes	Somewhat
No	Don't Know

Comments

16. I feel safe and comfortable here.

Yes	Somewhat
No	Don't Know

Comments

17. People respect my privacy.

Yes	Somewhat
No	Don't Know

Comments

18. The facility manages my personal funds.

Yes	Somewhat
No	Don't Know

Do you have concerns about how the facility is handling your funds?

Comments

19. The facility gives me WRITTEN notices of any changes in fees or services at least 30 days before the change happens.

Yes

Not Applicable

Comments

20. Do you control and take your own medications?

Yes	Somewhat
No	Don't Know

Have either you or your doctor signed a paper allowing the facility to control your medications and give them to you?

Yes

Comments

21. If the facility assists me with my medications, I receive them

on time

Yes	Somewhat
No	Don't Know

Comments

in an acceptable manner

Yes	Somewhat
No	Don't Know

Comments

as prescribed by my doctor

Yes	Somewhat
No	Don't Know

Comments

22. Any other comments regarding this facility you would like to make?

Other Person(s) Assisting Resident in Completing this Evaluation

Name – Guardian / Representative

Date Signed

Name – AFH Staff

Date Signed

Supervision	Leisure time activities	Family contacts	Health monitoring
Medication Management	Help with personal care	Help in communication	Assistance in decision-making
Information and Referral	Activities in the community	Transportation	Access to medical services
Limited nursing services	Help with independent living skills	Opportunity to socialize with others	Transition services