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. Please selectYesNo Did you feel that you were discriminated against or saw any discrimination. Please selectYesNo Were you properly informed of residents and job responsibilities for your assigned hall. Please selectYesNo Do you feel the facility’s working environment is safe and productive for staff and residents. Please selectYesNo Was the facility short staffed Please selectYesNo Could you find assistance easily when needed. Please selectYesNo Did you have to perform other employees’ jobs. Please selectYesNo Do you believe that there was enough staff to provide all needed services to residents.. Please selectYesNo Were call lights being answered in a timely manner. Please selectYesNo Were there many residents left in their bed. Please selectYesNo Were the majority of residents active. Please selectYesNo If worked during meals, were meals served hot and on time. Please selectYesNo Were sanitation and proper ethics carried out by staff. Please selectYesNo Was staff friendly, helpful, and gave encouragement. Please selectYesNo Were all medications and supplies available. Please selectYesNo Was all equipment available and working properly. Please selectYesNo Were you given your breaks and lunch. Please selectYesNo Facility up to city and government codes and regulations. Please selectYesNo Were you relieved on time. Please selectYesNo Would you be willing to work at this facility again. Please selectYesNo At this facility did you feel your license could be in jeopardy. Please selectYesNo Do you feel residents’ rights are being violated at this facility. Please selectYesNo Did you find your time to be more stressed than usual at this facility. Please selectYesNo Thoughts on Administrator. Please selectGreatGoodPoorHorrible Were protocols and chain of command in place and being followed. Please selectYesNo Other Comments Today's Date Your Name Position