Care Home Survey
Please help us provide the most information we can to our agents about your home by completing this survey.
Name of Home
Your answer
Contact Person's First Name
Your answer
Contact Person's Last Name
Your answer
Contact Person's Email Address
Your answer
Do you have liability insurance?
How many private beds do you have?
How many semi-private beds?
Are you approved for ALTCS:
If yes, which plan/s?
Are private pets allowed?
Do you have 24 hour AWAKE night staff?
If your home has memory care safety features, please explain them:
Your answer
Are your caregivers on shifts or do they live-in?
Does the owner and/or manager have any medical background?
If yes, please explain.
Your answer
Please check the correct box for each of the following specialties:
Check if you accept residents with the following:
Check if you have completed specialized training on caring for residents with the following conditions?
Non-Dementia Behaviors
Colostomy Care Needs
COPD
Diabetes Management
Moderate-Severe Dementia
Parkinson's
Stroke
TBI (Traumatic Brain Injury)
Trache Care Needs
Wound Care Needs
Catheter Care Needs
Bedbound
Chronic Heart Failure
Anxiety and Depression
What languages other than English does your staff speak?
Your answer
Do you accept residents under 65?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms