* = Required Information

Your Name * 
Date * 
Tel. No. 
Fax No. 
Email 

1. Were you involved in the decision making regarding your care plan? *

Yes No Don't Know 
Comments: 

2. Was the staff usually the same staff providing home health services to you and generally arrived when you expected? *

Yes No Don't Know 
Comments: 

3. Did staff members identify themselves as home health care agency employees by stating their names and title? *

Yes No Don't Know 
Comments: 

4. Did the home care staff explain your rights and responsibilities as a client? *

Yes No Don't Know 
Comments: 

5. Did the staff treat you, your family, your home and belongings with respect? *

Yes No Don't Know 
Comments: 

6. Was the staff courteous, compassionate, and did you feel safe when they were in your house? *

Yes No Don't Know 
Comments: 

7. Did you understand how to register a complaint? Were you told about the State Home Health hotline? *

Yes No Don't Know 
Comments: 

8. Did staff promptly and adequately respond to your needs, concerns and problems? *

Yes No Don't Know 
Comments: 

9. Did you know where to a call for help with emergencies 24 hours a day? *

Yes No Don't Know 
Comments: 

10. Was your discharge from our agency efficient? *

Yes No Don't Know 
Comments: 

11. Did the staff make it clear to you as to who was financially responsible? *

Yes No Don't Know 
Comments: 

12. Would you use our home heath care services in the future, if necessary and recommend us to your family and friends? *

Yes No Don't Know 
Comments: 

13. Types of services that were provided to me: (Please choose below) *

Skilled Nursing
Physical Therapy
Occupational Therapy
Speech Therapy
Medical Social Services
Home Health Aide
How can we improve our service and/or communication:

Security Code *