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* 1. Who are you filling this survey for:

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* 2. Is the person you are filling the survey for currently in a long-term care facility?

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* 3. How old was the resident when diagnosed with Celiac Disease?

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* 4. How long has the resident been in the current facility?

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* 5. Did you find it difficult finding a placement in a facility specifically due to celiac disease?

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* 6. Other than a gluten-free diet, what other types of diet is the resident following?

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* 7. What meal texture your family member is receiving

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* 8. Did you or a family member discuss at length the requirements for the GF diet with staff?

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* 9. If you answered yes to the previous question, who did you discuss it with? Check all that apply.

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* 10. How does your family member or friend access food? Check all that apply.

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* 11. Does your family member require assistance with feeding?

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* 12. What types of accommodations are made in the facility to provide gluten-free meals to the resident:

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* 13. How would you estimate the level of knowledge on gluten-free diet and cross-contamination of the food service staff in the facility?

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* 14. How would you estimate the level of knowledge on gluten-free diet and cross-contamination of the staff helping in feeding the resident in the facility?

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* 15. What your estimation is based on: Check all that apply.

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* 16. Rate how confident you are that the resident is receiving uncontaminated food?

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* 17. How would you rate the quality of the diet (nutrition, variety, quality)?

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* 18. Has the resident had any illnesses directly related to cross-contamination of their celiac diet in the LTC facility?

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* 19. If you answered yes to illness related to cross-contamination question, was the resident ever admitted to hospital for treatment?

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* 20. If you are filling this survey for a family member or friend, is the resident aware of their CD diagnosis (mentally capable):

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* 21. What Province is the resident located?

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* 22. Do you have any other comments, questions, or concerns?

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* 23. Would you like to share your story with us?

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