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.

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* Please click on your facility type:


Facility Type	Facility Type menu

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* Facility Name:

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* License Number:

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* Date of Survey/Inspection:

Exit Date

Date

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* Please click on the type(s) of survey/inspection you had (mark all that apply):

Initial Certification

Recertification

Initial Licensure

Licensure

Complaint Investigation

Follow-up Visit

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* Rate each statement from Strongly Agree to Strongly Disagree

	Strongly Agree	Somewhat Agree	Neither Agree nor Disagree	Somewhat Disagree	Strongly Disagree	Not Applicable
Explained clearly the survey process during the entrance conference.	Explained clearly the survey process during the entrance conference. Strongly Agree	Explained clearly the survey process during the entrance conference. Somewhat Agree	Explained clearly the survey process during the entrance conference. Neither Agree nor Disagree	Explained clearly the survey process during the entrance conference. Somewhat Disagree	Explained clearly the survey process during the entrance conference. Strongly Disagree	Explained clearly the survey process during the entrance conference. Not Applicable
Provided adequate explanation and assistance to complete the necessary forms.	Provided adequate explanation and assistance to complete the necessary forms. Strongly Agree	Provided adequate explanation and assistance to complete the necessary forms. Somewhat Agree	Provided adequate explanation and assistance to complete the necessary forms. Neither Agree nor Disagree	Provided adequate explanation and assistance to complete the necessary forms. Somewhat Disagree	Provided adequate explanation and assistance to complete the necessary forms. Strongly Disagree	Provided adequate explanation and assistance to complete the necessary forms. Not Applicable
Gave adequate opportunity to provide survey-related data and other relevant information.	Gave adequate opportunity to provide survey-related data and other relevant information. Strongly Agree	Gave adequate opportunity to provide survey-related data and other relevant information. Somewhat Agree	Gave adequate opportunity to provide survey-related data and other relevant information. Neither Agree nor Disagree	Gave adequate opportunity to provide survey-related data and other relevant information. Somewhat Disagree	Gave adequate opportunity to provide survey-related data and other relevant information. Strongly Disagree	Gave adequate opportunity to provide survey-related data and other relevant information. Not Applicable
Presented survey/inspection findings clearly and concisely during the exit interview.	Presented survey/inspection findings clearly and concisely during the exit interview. Strongly Agree	Presented survey/inspection findings clearly and concisely during the exit interview. Somewhat Agree	Presented survey/inspection findings clearly and concisely during the exit interview. Neither Agree nor Disagree	Presented survey/inspection findings clearly and concisely during the exit interview. Somewhat Disagree	Presented survey/inspection findings clearly and concisely during the exit interview. Strongly Disagree	Presented survey/inspection findings clearly and concisely during the exit interview. Not Applicable
Clarification and explanation before the team's departure of any differences that arose during the survey.	Clarification and explanation before the team's departure of any differences that arose during the survey. Strongly Agree	Clarification and explanation before the team's departure of any differences that arose during the survey. Somewhat Agree	Clarification and explanation before the team's departure of any differences that arose during the survey. Neither Agree nor Disagree	Clarification and explanation before the team's departure of any differences that arose during the survey. Somewhat Disagree	Clarification and explanation before the team's departure of any differences that arose during the survey. Strongly Disagree	Clarification and explanation before the team's departure of any differences that arose during the survey. Not Applicable
Professionalism and courtesy with your staff.	Professionalism and courtesy with your staff. Strongly Agree	Professionalism and courtesy with your staff. Somewhat Agree	Professionalism and courtesy with your staff. Neither Agree nor Disagree	Professionalism and courtesy with your staff. Somewhat Disagree	Professionalism and courtesy with your staff. Strongly Disagree	Professionalism and courtesy with your staff. Not Applicable
Professionalism and courtesy with residents/clients.	Professionalism and courtesy with residents/clients. Strongly Agree	Professionalism and courtesy with residents/clients. Somewhat Agree	Professionalism and courtesy with residents/clients. Neither Agree nor Disagree	Professionalism and courtesy with residents/clients. Somewhat Disagree	Professionalism and courtesy with residents/clients. Strongly Disagree	Professionalism and courtesy with residents/clients. Not Applicable
Responsiveness to questions/issues/concerns.	Responsiveness to questions/issues/concerns. Strongly Agree	Responsiveness to questions/issues/concerns. Somewhat Agree	Responsiveness to questions/issues/concerns. Neither Agree nor Disagree	Responsiveness to questions/issues/concerns. Somewhat Disagree	Responsiveness to questions/issues/concerns. Strongly Disagree	Responsiveness to questions/issues/concerns. Not Applicable

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* Do you want a Program Manager from the Licensure Unit to contact you about the survey conducted at your facility?

Yes