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This survey asks for your opinions about resident safety issues in your nursing home. It will take about 15 minutes to complete.
If a question does not apply to your job or you do not know the answer, please mark the box in the last column. If you do not wish to answer a question, you may leave your answer blank.
- In this survey "resident safety" means preventing resident injuries, incidents, and harm to residents in the nursing home.
Please do NOT use the 'Back' or 'Refresh' buttons in your browser while taking the survey. This might create errors during filling up or submitting the survey.
Section A: Working in This Nursing Home |
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How much do you agree or disagree with the following statements?
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Section B: Communications |
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How often do the following things happen in your nursing home?
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Section C: Your Supervisor |
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How much do you agree or disagree with the following statements?
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Section D: Your Nursing Home |
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How much do you agree or disagree with the following statements?
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Section E: Overall Ratings |
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I would tell my friends that this is a safe nursing home for their family. |
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Please give this nursing home an overall rating on resident safety. |
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Section F: Background Information In this survey, think of your "unit" as the work area, department, or clinical area of the hospital where you spend most of your work time or provide most of your clinical services.
Physicians - Please use your best judgment to select the unit where you provide the most service. |
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What is your primary work unit? |
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What is your job in this nursing home? Check the box that best applies to your job. If more than one category applies, check the highest level job. |
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How long have you worked in this nursing home? |
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How many hours per week do you usually work in this nursing home? |
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When do you work most often? |
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Are you paid by a staffing agency when you work for this nursing home? |
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In your job in this nursing home, do you work directly with residents most of the time? |
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In this nursing home, where do you spend most of your time working? |
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| Section G: Your Comments
Please feel free to write any comments about resident care and safety in this nursing home. | | |
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