REPORT ABUSE Agency Staff – Call Light Coalition

Agency staff

Facility Name*

City*

State*

While working in this facility did you experience or notice any of the following

Were you sexually harassed or had to deal with any inappropriate behavior.

Did you feel that you were discriminated against or saw any discrimination.

Were you properly informed of residents and job responsibilities for your assigned hall.

Do you feel the facility’s working environment is safe and productive for staff and residents.

Was the facility short staffed

Could you find assistance easily when needed.

Did you have to perform other employees’ jobs.

Do you believe that there was enough staff to provide all needed services to residents..

Were call lights being answered in a timely manner.

Were there many residents left in their bed.

Were the majority of residents active.

If worked during meals, were meals served hot and on time.

Were sanitation and proper ethics carried out by staff.

Was staff friendly, helpful, and gave encouragement.

Were all medications and supplies available.

Was all equipment available and working properly.

Were you given your breaks and lunch.

Facility up to city and government codes and regulations.

Were you relieved on time.

Would you be willing to work at this facility again.

At this facility did you feel your license could be in jeopardy.

Do you feel residents’ rights are being violated at this facility.

Did you find your time to be more stressed than usual at this facility.

Thoughts on Administrator.

Were protocols and chain of command in place and being followed.

Other Comments

Today's Date

Your Name

Position