Facility Name:
Phone Number:
Date:
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
