EOEA Certification/Ombudsman/OSHA Specialist Visit Questionnaire

Thank you for taking a few minutes to share with Mass-ALA the results of your recent interaction with an EOEA Assisted Living Certification Specialist or other regulators. Please note: We will not share your information with EOEA or any other regulator.

By completing this questionnaire and sharing your information, you will assist us in identifying industry issues and trends, developing our advocacy initiatives and strategies, and recognizing industry training needs.

If you have any questions about this questionnaire or have any other regulatory or quality improvement concerns, please contact Laurie Cashman, Director of Education, at lcashman@mass-ala.org or 781 622-5999 x103.

Question Title

* 1. Answers to this section are optional. If you wish to remain anonymous, please proceed to question 4. If you are comfortable providing this information, please complete each line. Mass-ALA will not share your information with any entity.

Community Name

Your email

Date of your survey

Is your community certified as a special care residence?

Question Title

* 2. Purpose of Interaction.

Initial Certification

Recertification Review

Other EOEA visit

Ombudsman Visit

OSHA Inspection

Follow-up Visit

Phone Call

If other, please specify.