This survey has been prepared by the CF Patient/Family Advisory Board (*) and is designed to measure your level of satisfaction with the housekeeping service on your ward. This survey is completely voluntary and anonymous. We welcome your feedback and are committed to providing you with a clean environment.

*The Patient/Family Advisory Board (PFAB) is an advisory resource to the St. Michael's care team. Our objectives are to collaboratively work with the CF team in order to actively participate in the development of new programs, review recommendations, and provide input with the ultimate goal of shaping a service system (the clinic) that is patient/family centred, efficient, and cost effective. You can reach the PFAB team via email at cf.pfab.toronto@gmail.com

You can also visit us online at http://torontoadultcf.com/your-centre/patient-family-advisory-board-pfab

Thank you for your contribution!

* 1. Date the survey was completed

Enter the date you completed the survey
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* 2. Date of admission

Please enter the date you were admitted
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* 3. Upon admission, please rate your satisfaction with the cleanliness of the following items in your room:

Please answer each line item.

  Acceptable Not Acceptable Not Applicable
Floor
Bedside nightstand
Bedside table
Bed and railings
Garbage bins
Privacy curtains (stained/unstained)
Fridge (if applicable)

* 4. Upon admission, please rate your satisfaction with the cleaniness of the following items in your bathroom:

Please answer each line item.

  Acceptable Not Acceptable Not Applicable
Floor
Toilet
Sink and taps
Paper towel dispenser
Soap dispenser
Shelf

* 5. Upon admission, did you feel that you needed to clean your room yourself, or have a family member clean it for you, because you felt it wasn't clean enough?

* 6. During your hospital admission, please rate how satisfied with the daily maintenance/cleaning of the following items:

Please answer each line item.

  Acceptable Not Acceptable Not Applicable
Floor-swept and mopped
Bathroom sink
Toilet
Bathroom surfaces (ie: shelves, paper towel rack)
Garbage emptied at least one per day
Does housekeeping staff wash or sanitize their hands when entering patient's room
Does the housekeeping staff wear a gown and gloves when entering a patient's room

* 7. Please rate your overall level of satisfaction with the cleaniness of your room during the course of your admission.

* 8. Are there any other comments you have about the housekeeping services on your ward?

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