Question Title

* 1. Facility name:

Question Title

* 2. What is your admittance status?

Question Title

* 3. Who do you contact when you have a problem with your care in the facility? Check all that apply.

Question Title

* 4. How did you hear about the Ombudsman program?

Question Title

* 5. Do you understand your resident's rights?

Question Title

* 6. How did you learn about resident's rights?

Question Title

* 7. Do you understand what the Ombudsman Program does?

Question Title

* 8. Do you want to know more about the Ombudsman Program?

Question Title

* 9. Do you know how to contact the Ombudsman?

Question Title

* 10. Have you ever asked the Ombudsman for help?

Question Title

* 11. Below are a few statements that describe how you feel about the Ombudsman services. For each statement, please check the box of response that best describes the statement that applies to you. Skip this question if you have never received assistance from the Ombudsman.

  Strongly agree Agree Disagree Strongly disagree
I am satisfied with the way the Ombudsman handled my problem
My problem was resolved to my satisfaction
I am satisfied with the time it took to handle my problem
I had sufficient contact with the Ombudsman while my problem was being resolved
My problem has not reoccurred
I would recommend the Ombudsman program to other residents who need help

Question Title

* 12. If you were dissatisfied with the outcome of your complaint, please explain why.

0 of 12 answered
 

T