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Employee Information
First Name:
*
Last Name:
*
Email:
*
Guest Information
First Name:
*
Last Name:
*
Email:
Mobile/Phone:
Location:
*
Please select a location...
Barnwell
Batavia
Chestnut Park
Chittenango
Colonial Park
Delaware Park
Great Neck
Guilderland
Mayfair
Mohawk Valley
Pawling
Queens
River Valley
Robinson Pavilion
Robinson Terrace (SNF)
Rochester
Rome
South Point
Utica
Relationship to Resident:
*
Self
Spouse
Parent
Child
Do you have any comments, questions, or concerns?
Any comments can be used for marketing purposes
Questions
(1 - very unsatisfied , 2 - unsatisfied, 3 - neutral, 4 - satisfied, 5 - very satisfied )
1.
What hospital were you referred from?
2. Date of Admission
3. Room Number
4. Did you feel welcomed by the staff members?
1
2
3
4
5
5. When using your call button, how often did you get help as soon as you wanted it?
1
2
3
4
5
6. Do all staff treat you with courtesy and respect?
1
2
3
4
5
7. Is the area around your room quiet at night?
1
2
3
4
5
8. Does the nursing staff listen carefully to you and explain things to you?
1
2
3
4
5
9. Do you feel you are on task with your therapy sessions?
1
2
3
4
5
10. Do you have any favorite activities?
11. Would you be interested in going to the activities that we offer here?
Yes
No
12. Who is doing your laundry?
13. Was your clothing labeled?
Yes
No
14. Is your room clean, free of odor, and presentable?
1
2
3
4
5
15. Are the meals enjoyable, tasty, and satisfying?
1
2
3
4
5
16. Are you satisfied with the appearance and temperature of your food when it arrives?
1
2
3
4
5
17. Would you like to try the Grandwich of the week or choose from the "always available list"?
Yes
No
18. Is there anything we can do to make your stay here more comfortable?
19. How did you hear about the Grand?
