* Required Information
Consumer/Family Member
*
Date
*
Staff
*
Service
*
1. Interaction between the staff and consumer/family member is.
1-Very Poor
2
3
4
5-Excellent
2. Staff ability to manage or handle the consumers’ behavior problem or needs.
1-Very Poor
2
3
4
5-Excellent
3. Staff ability to handle the consumers’ routine activities (mealtimes, bedtime, bathing, etc.).
1-Very Poor
2
3
4
5-Excellent
4. If applicable, how well did the provider/staff handle emergency situations which arose?
1-Very Poor
2
3
4
5-Excellent
5. To your knowledge, how well does the staff make use of routine attempts to teach the consumer self-care, life skills, academic or other skills?
1-Very Poor
2
3
4
5-Excellent
6. Does staff report all relevant information to you prior to his/her departure after the shift?
1-Very Poor
2
3
4
5-Excellent
7. Overall, how do you rate the quality of care that is provided?
1-Very Poor
2
3
4
5-Excellent
Performed By:
Method Used:
Telephone
Mail
Interview Onsite
By submitting this form you agree to the terms of the
Privacy Policy
.