Facility Name:
Phone Number:
Date:
February 2012
S
M
T
W
T
F
S
5
29
30
31
1
2
3
4
6
5
6
7
8
9
10
11
7
12
13
14
15
16
17
18
8
19
20
21
22
23
24
25
9
26
27
28
29
1
2
3
10
4
5
6
7
8
9
10
What time of day was the visit?
6 AM - 9 AM
9 AM - 12 PM
12 PM - 3 PM
3 PM - 6 PM
Please select the areas where you found a need for improvement:
General accessibility
General Care from Physicians/Staff
Admission process
Food/Meals
Billing
Visitor and Family visiting hours
Hospital Environment
Were each of the following checked thoroughly for cleanliness?
Yes
No
N/A
Restrooms
Waiting Room
Hospital Beds
Reception Area
Entrance Ways