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 regulator.

Please note: We will NOT share your information with EOEA or any other regulating body.

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 if you have any other regulatory or quality improvement concerns, please contact us at info@mass-ala.org or call 781-622-5999.

Question Title

* 1. Answers to this section are optional. If you wish to remain anonymous, please proceed to the next question. 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

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.

Question Title

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

Question Title

* 2. Purpose of Interaction.

Question Title

* 3. What is the date(s) of your survey/interaction?