Division of Public Health, Licensure Unit, Survey/Inspection Facility Evaluation Form

Time is important and so are your comments and suggestions. Please take this opportunity to tell us how we did on your most recent survey/inspection. The Nebraska Department of Health and Human Services (DHHS), Division of Public Health, asks your assistance in helping us evaluate and improve our survey/inspection process. Your comments and suggestions are a vital part of our ongoing evaluation and improvement efforts.

To ensure confidentiality, the identity of the facility completing the survey is not disclosed to the survey/investigation team. If you choose to identify yourself and the facility for which you work, it will provide the Division of Public Health and/or Licensure Unit with an opportunity to seek your additional comments and suggestions about improving our process. Either way, your ratings and comments will be kept confidential.

We appreciate your candid responses and the opportunity to work with you on our shared goals of quality health services.
If you would like to be contacted regarding any of your responses or if you have specific areas of concern regarding the survey conducted at your facility, please provide your name:
If you would like to be contacted regarding any of your responses or if you have specific areas of concern regarding the survey conducted at your facility, please provide your phone number (000-000-0000):
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Please click on your facility type:
Facility Type
Facility Name:
License Number:
Date of Survey/Inspection:
MM DD YYYY
Exit Date
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Please click on the type(s) of survey/inspection you had (mark all that apply):
Please rate the survey/inspection team's performance in the following areas:
Strongly Agree (5)Somewhat Agree (4)Neither Agree nor Disagree (3)Somewhat Disagree (2)Strongly Disagree (1)Not Applicable (NA)
1. Explained clearly the survey process during the entrance conference.
2. Provided adequate explanation and assistance to complete the necessary forms.
3. Gave adequate opportunity to provide survey-related data and other relevant information.
4. Provided adequate opportunity during status meetings to discuss and question survey findings.
5. Presented survey/inspection findings clearly and concisely during the exit interview.
6. Clarification and explanation before the team's departure of any differences that arose during the survey.
7. Professionalism and courtesy with your staff.
8. Professionalism and courtesy with residents/clients.
9. Responsiveness to questions/issues/concerns.
Do you have comments or suggestions about the survey/investigation experience that could help us improve our process? Please feel free to provide additional information in the box below. Thank you for completing this survey!