Participant Feedback Form
We’d love to hear about your customer experience. Feel free to share suggestions, ideas, or anything that comes to mind.
First name
Last name
Email
Are you satisfied with the help you get from staff?
Yes
No
Do you feel staff and other people respect your privacy?
Yes
No
Does the staff treat you with respect?
Yes
No
Do you feel that staff members listen to you request?
Yes
No
Are you satisfied with the meals?
Yes
No
Are you satisfied with how you spend your day?
Yes
No
Are you satisfied with the activities provided?
Yes
No
Do you participate in the daily activities?
Yes
No
Are there additional activities you would like to see offered?
Do you feel safe at the day center?
Yes
No
Do you participate in fire drills?
Yes
No
Overall, are you satisfied with the day center?
Yes
No
Did you participate in developing your care plan?
Yes
No
Is there anything else you would like to talk about concerning your time here?
Please share any suggestions or ideas for improvement.
Send Feedback
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