REPBUSE Administrative – Call Light Coalition

Administrative

Facility Name*

Address*

Owner/CEO*

Do you have all the resources needed for a safe and productive facility?

Do you believe incidents of neglect in your facility are out of your control?

Is your facility accepting new residents?

Most incidents involving residents could be prevented if you had the right support and tools?

Could low or lazy staff factor in residents being neglected in your facility?

Could low or lazy staff be the root cause of your staff's anxiety and well-being?

Could incidents not under your control in your facility result in your staff or yourself losing their license, certification or worse?

Do you believe staff are affected by above normal job stress levels?

Does your facility have trouble staffing shifts?

Have you tried to contact corporate?

Do you believe corporate management have knowledge of your facility's situation?

Do you feel the owner/CEO of your facility is intimidating or arrogant?

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?

Do you feel corporate management does enough for your residents and staff's well-being and safety?

Are you able to make and enforce critical decisions and changes concerning your facility?

Has any corporate management member ever sexually harassed, threatened, or violated your rights?

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

Administrative

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