Resident & Family Satisfaction Questionnaire
Page One
1.
Please enter your contact information
First Name
Last Name
2.
Please tell us your relationship to the patient
-- Please Select --
Patient
Family Member
Other/Unknown
3.
Date of Response
4.
WELCOME AND ARRIVAL
Better than Expected
As Expected
Less than Expected
Friendliness of front desk personnel
Staff provided help in getting settled in
Explanations regarding billing and insurance
5.
ROOM
Better than Expected
As Expected
Less than Expected
Room and bathroom cleanliness
Comfortable bed & furniture
Proper functioning of lights, TV, phone, etc.
6.
MEALS
Better than Expected
As Expected
Less than Expected
Meals were served adequately hot
Meals were appetizing and nutritious
Preferences regarding meals was honored
7.
SKILLED CARE & REHABILITATION
Better than Expected
As Expected
Less than Expected
Staff included me in developing my rehab goals
Staff offered treatment and comfort for pain
Alternative interventions offered (warm blanket, moist heat)
8.
DISCHARGE PLANNING
Better than Expected
As Expected
Less than Expected
Staff included me in planning my discharge goals
Staff made the discharge as easy as possible
9.
GENERAL
Better than Expected
As Expected
Less than Expected
Staff responded to my needs & concerns
Staff treated me with dignity and respect
Staff were knowledgeable
An overall environment that supports recovery
10.
What made you decide to come to Mira Vista?
-- Please Select --
Referral from physician
Referral from hospital discharge planner
Referral from family or friend
Close to home
Reputation of Facility/Rehab
Stayed here before
Other
11.
Who are the staff members who provided you with outstanding service?
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
12.
How likely is it that you will recommend Mira Vista to a friend or relative who needed our services?
Very Likely
Possibly
Not Likely
No Answer
13.
Any additional or final comments?
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