Request edit access
Quality Care Staffing Nursing Homes Survey
Nursing Home name
Your answer
Date
MM
/
DD
/
YYYY
Your name
Your answer
Your phone
Your answer
Your email
Your answer
Your preferred contact method
How many floors or units does this nursing home have?
Your answer
Which shift is this survey being filled out for?
How many residents are currently occupying this nursing home?
Your answer
Does this home have a unit designated for a particular type of patient (i.e. long-term, ventilator, rehab, etc.)?
How many CNAs actually worked in the entire facility during this shift (1199)?
Your answer
How many CNAs actually worked in the entire facility during this shift (Agency)?
Your answer
If the number of CNAs SCHEDULED TO WORK was different, enter that here (1199):
Your answer
If the number of CNAs SCHEDULED TO WORK was different, enter that here (Agency):
Your answer
How many 1199 or non-union employees actually worked in the entire facility, providing direct patient care, during this shift (Agency)?
Your answer
If the number of 1199 or non-union employees SCHEDULED TO WORK was different, enter that here (1199):
Your answer
If the number of 1199 or non-union employees SCHEDULED TO WORK was different, enter that here (Agency):
Your answer
How many RNs actually worked in the entire facility, providing direct patient care, during this shift (1199)?
Your answer
How many RNs actually worked in the entire facility, providing direct patient care, during this shift (Non-1199)?
Your answer
How many RNs actually worked in the entire facility, providing direct patient care, during this shift (Agency)?
Your answer
If the number of RNs SCHEDULED TO WORK was different, enter that here (1199):
Your answer
If the number of RNs SCHEDULED TO WORK was different, enter that here (Non-1199):
Your answer
If the number of RNs SCHEDULED TO WORK was different, enter that here (Agency):
Your answer
If possible, take a photo of the staffing schedule showing short staffing or the difference between what was scheduled vs who actually worked and email it to jen.cancellieri@1199.org or text to 443-602-5698
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service