Dear Patient:

Absolute Care valued your opinion about the services providing to you. Please take your time to complete this survey telling us how we are doing. Your answers will help us improve services to you.

Your answer will not affect the services you are receiving instead it will help us improve them. Your name is optional. The survey will not be shared with your nurse.

Please mail the survey with the enclosed self address envelope.

Thank you for your time.

* = Required Information
TELL US ABOUT YOURSELF:
What is your name?
What is your gender?
Female Male
What is your age group?
Infant Under 18
18-39 40-64
65 +
Which best describe you?
African-Ame. Asian
Caucasian Hisp
Other
TELL US ABOUT SERVICES YOU RECEIVE:
  Rating: Strongly Agree=4, Agree=3, Undecided=2, Disagree=1
 
Is this your first time receiving services from Absolute Care?
Yes No
If yes, When? Please list dates From
To
The nurse arrived on time for initial assessment. 1234
The nurse answered all my questions during initial assessment. 1234
I found the Patient Education handbook very useful. 1234
Absolute Care guide for Activities of Daily Living was useful for me and my family to determine my Plan of Care. 1234
The personal care Aide assigned to you arrives on time. 1234
My Aide provides services according to my Plan of Care. 1234
My learning needs and expectation were met. 1234
My calls to the Agency were returned within 24 hours. 1234
I fell this Agency treats me with respect and dignity. 1234
What services/activities do you found most useful?
What do you suggest changing or improving?
What result do you expect to see at discharge?
How will you rate the services provided by this Agency? Strongly SatisfiedSatisfiedUndecidedDissatisfiedStrongly Dissatisfied