Ask Me If I Cleaned My Hands

1. BE A PARTNER IN YOUR OWN CARE!

Please observe the service provider visiting to see if they are washing their hands or using an alcohol based hand rub before and after they provide service to you or your loved one. Your active participation in your care or the care of your loved one is important to us and we value your feedback. Our goal is to provide you with safe service. Cleaning our hands using soap and water or alcohol based hand rub helps to prevent the spread of germs.

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* 1. What Better Living family organization is this feedback for?

Better Living Health and Community Services

Meals on Wheels and More

Doane House Hospice

Margaret Bahen Hospice

Better Living at Thompson House

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* 2. When did you observe the service provider?

Date

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* 3. Who Visited You?

Personal Support Worker

Home Support Worker

Driver

Visiting Volunteer

Case Manager

Adult Day Program Recreationist

Nurse

Physician

Recreationist

Other (please specify)

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* 4. Did your service provider use proper hand hygiene before and after service?

	Yes	No	Not Sure
Before Service Started	Before Service Started Yes	Before Service Started No	Before Service Started Not Sure
After Service Finished	After Service Finished Yes	After Service Finished No	After Service Finished Not Sure

Ask Me If I Cleaned My Hands

1. BE A PARTNER IN YOUR OWN CARE!

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* 1. What Better Living family organization is this feedback for?

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* 2. When did you observe the service provider?

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* 3. Who Visited You?

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* 4. Did your service provider use proper hand hygiene before and after service?

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* 5. Please share any other comments you have below: