Administrative Facility Name* Address* Owner/CEO* Do you have all the resources needed for a safe and productive facility? Please selectYesNo Do you believe incidents of neglect in your facility are out of your control? Please selectYesNo Is your facility accepting new residents? Please selectYesNo Most incidents involving residents could be prevented if you had the right support and tools? Please selectYesNo Could low or lazy staff factor in residents being neglected in your facility? Please selectYesNo Could low or lazy staff be the root cause of your staff's anxiety and well-being? Please selectYesNo Could incidents not under your control in your facility result in your staff or yourself losing their license, certification or worse? Please selectYesNo Do you believe staff are affected by above normal job stress levels? Please selectYesNo Does your facility have trouble staffing shifts? Please selectYesNo Have you tried to contact corporate? Please selectYesNo Do you believe corporate management have knowledge of your facility's situation? Please selectYesNo Do you feel the owner/CEO of your facility is intimidating or arrogant? Please selectYesNo Do you feel that your facilities corporate management team provides your facility with needed support and supplies so staff can provide all services in a timely manner? Please selectYesNo Do you feel corporate management does enough for your residents and staff's well-being and safety? Please selectYesNo Are you able to make and enforce critical decisions and changes concerning your facility? Please selectYesNo Has any corporate management member ever sexually harassed, threatened, or violated your rights? Please selectYesNo If answered yes to the previous question please fill in the following questions Their name Title Date incident/incidents Description of complaint What do you believe would make your facility better. *I swear to have answered all the questions above as truthful as to my knowledge and have not been harmed or intimidated in anyway. Yes Name* Today's Date
