* = Required Information
Name: *
Phone No. *
Address: *
Email: *
 
Please tick "Yes" or "No" for the following questions.
Please explain your reason(s) for "No" responses in the "Comments" section at the end of the questionnaire.
No. Question Yes No
  Organization & Administration    
1. Did you find us easy to contact?
2. Do you feel we responded in a timely manner?
3. Did we give you information on the following:
      – Brochure/other documentation about our services
      – Service Agreement
      – Rights & Responsibilities
      – Contact details & numbers within normal office hours
      – Contact details & numbers outside normal office hours
      – How to make a complaint, including who to contact
      – Elder Abuse Hotline Number













4. Were you introduced to, or made aware of the Home Care Worker(s) assigned to you, prior to commencement of service?
5. Do you feel your needs/wants are being met & are being provided, in accordance with what was agreed upon?
  Service Delivery    
6. Was a personal Service Plan developed & implemented?
7. Were you/your representative involved in developing the Service Plan?
8. Do you feel you are cared for in a comfortable & non discriminatory way?
9. How many Home Care Workers are usually involved in your care?
10. Does your Home Care Worker(s) show up for work on time?
11. Does your Home Care Worker(s) stay for the specified time?
12. Does your Home Care Worker(s) assist you with your medication? If "Yes", give specific details.
13. Does a Supervisor occasionally make a home visit?
14. Are you notified in advance if your Home Care Worker is going to be changed?
15. Is there anything that concerns you about your Home Care Worker(s)?
16. Were you advised who would be supervising your Home Care Worker(s)?
17. Are you notified in advance if your regular services have to be rescheduled?
18. Were you advised who you/your representative/family may contact should you wish to speak to someone other than your Home Care Worker(s)?
19. Were you advised that we may employ both male & female workers?
20. Were you asked if you prefer a male or female worker?
21. Is your normal daily routine followed as much as possible within the provision of personal care such as getting up, meal times & bathing arrangements?
22. Do you find us to be:
      – friendly
      – considerate
      – polite
      – respectful
      – honest
      – believable
      – prompt
      – dependable
      – efficient
      – approachable



















  Financial Matters    
23. Do Home Care Workers shop and/or handle money for you?
24. If Home Care Worker(s) shop and/or handle money for you, do they always return the change and receipt(s)?
25. If Home Care Worker(s) return change and receipts to you, do you both sign the Financial Transactions Record?
26. Do Home Care Workers have you sign their Employee Time Sheet after each visit?
27. Do you feel we have the required knowledge & skills to deliver service?
28. Is there anything you don't like about our service?
29. Have you any suggestions for ways we can improve our service?
30. Would you use our services in the future?
31. Would you recommend us to others?
32. How would you rate the overall quality of service you receive?
Poor Fair Good Excellent
33. How would you rate the Home Care Worker(s) treatment of you?
Poor Fair Good Excellent
34. How do you view the quality of service to its cost?
Poor Fair Good Excellent
Comments: