1. Default Section

• Please answer each question below by checking the box that best indicates your opinion.
• If a question does not apply to you , please check the Not Applicable (N/A) box on the far right.
• There is space provided for your comments. If you need more space, please use the back of the questionnaire.

* 1. Please select what program you reside in:

* 2. Activities

  Yes, Always Yes, Sometimes No, Hardly Ever No, Never N/A
1. Do the activities here suit your abilities? (e.g. vision, hearing, mobility)
2. Is there enough variety in the activities offered here?
3. Can you make suggestions regarding the types of activities offered here?
4. Are bus trips offered here? (e.g. to shopping mall, community activities etc)

* 3. Choice

  Yes, Always Yes, Sometimes No, Hardly Ever No, Never N/A
6. Do you have choice in establishing your daily routine?
7. Do the staff let you do the things you want to do for yourself?
8. Are the rules here reasonable?

* 4. Care and Services

  Yes, Always Yes, Sometimes No, Hardly Ever No, Never N/A
9. Are snacks and drinks available to you?
10. Do the staff explain your care and services to you?
11. Do you get your medications on time?
12. Do the staff who take care of you know what you like and don’t like?

* 5. Staff Relations

  Yes, Always Yes, Sometimes No, Hardly Ever No, Never N/A
13. Are the staff courteous to you?
14. Can you depend on the staff? (e.g. do staff do what they say they will do, follow through?)
15. Are the staff here friendly to you?
16. Do the staff treat you with respect?

* 6. Staff Responsiveness

  Yes, Always Yes, Sometimes No, Hardly Ever No, Never N/A
17. During the week, are staff available to help you if you need it?
18. During the weekend, are staff available to help you if you need it?
19. During the evening and night, are staff available to help you if you need it?
20. Do you feel confident that the staff know how to do their job well?

* 7. Communication

  Yes, Always Yes, Sometimes No, Hardly Ever No, Never N/A
21. Are the people in charge available to talk with you? (e.g. managers, supervisors, administration)
22. Do the people in charge treat you with respect?
23. Would you feel comfortable making a complaint (to the people in charge)?
24. Do you know who to go to here when you have a problem?
25. Do your problems get taken care of? (e.g. are you problems addressed?)

* 8. Meals and Dining

  Yes, Always Yes, Sometimes No, Hardly Ever No, Never N/A
26. Is there enough variety in the food served?
27. At mealtimes is the alternative meal option suitable?
28. Is the food tasty?
29. Are the portions the right amount for you?
30. Is your food served at the right temperature (cold foods cold, hot foods hot)?
31. Are your special dietary needs accommodated? (e.g. allergies, intolerances, diabetic, vegetarian, kosher)

* 9. Housekeeping

  Yes, Always Yes, Sometimes No, Hardly Ever No, Never N/A
32. Do you get your flat linen (sheets and towels) back from the laundry?
33. Does your flat linen (sheets and towels) come back from the laundry in good condition?

* 10. Building Environment

  Yes, Always Yes, Sometimes No, Hardly Ever No, Never N/A
34. Are the building and grounds well maintained?
35. Can you easily access outside walkways and gardens?
36. Is access to the building secure?
37. Are the common areas kept clean enough for you? (e.g. lobby, dining area, lounge, hallways)
38. Are you able to get to the local shops?

* 11. Resident Environment

  Yes, Always Yes, Sometimes No, Hardly Ever No, Never N/A
39. Do staff respect your privacy ?
40. Do you feel safe here?
41. Are your belongings safe here?
42. Is your suite kept clean enough for you?
43. Can you keep your suite at the temperature you prefer?

* 12. Additional Questions

  Yes, Always Yes, Sometimes No, Hardly Ever No, Never N/A
42. Do you feel comfortable here?
43. Overall, do you like living here?
44. would you recommend this place to a family member or friend?
45. Overall, are you satisfied with the quality of care you receive here?
46. Overall, are you satisfied with the quality of hospitality services you receive here?
What changes would you like to see in your residence to improve your quality of life?
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