* = Required Information
Participant Name
*
Date
*
Medicaid #
Phone
*
Staff Involved
1. Are you aware of staff's schedule?
Yes
No
Comments
2. Is staff arriving for work as schedule?
Yes
No
Comments
3. Is staff arriving to work on time and staying the entire shift?
Yes
No
Comments
4. In your opinion, is staff performing their duties while at work?
Yes
No
Comments
5. In your opinion, is staff polite and courteous while at work.
Yes
No
Comments
6. Overall are you satisfied with our services?
Yes
No
Comments
7. List all current medication changes/emergency room or recent hospitalization.
Form Completed By
Date