* = Required Information
In what city/town did you receive care?
		Excellent Good Fair Poor
1. Overall satisfaction with the care provided by the:
a. Nurse (if you received services)
b. Home Health Aides (if you received services)
c. Physical Therapist (if you received services)
d. Social Worker (if you received services)
e. Occupational Therapist (if you received services)
f. Speech Language Pathologist (if you received services)
g. Dietition (if you received services)
2. The staff arrived as scheduled.
3. Staff was courteous and respectful.
4. Staff was knowledgeable and competent.
5. You were involved in decision making regarding our plan of care.
6. You were involved in planning for discharge from home health services.
7. Staff explained procedures related to care.
8. Office staff was courteous and directed phone calls correctly and promptly.
9. Would you use our agency again?
10. Would you recommend our services to others?
11. Additional Comments/Suggestions for Improvement:
Patient's Name (Optional)
* Security Code