Survey

Instructions
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1. Answer "Excellent", "Good", "Fair", "Poor" for the items below. Choose N/A if not applicable.
2. Add photos and notes by clicking on the paperclip icon. (Specify the room number in the notes)
3. Complete audit by providing digital signature.
4. Share your report by exporting as PDF, Word, Excel or Web Link.

Details

Interviewee

Employee

Supervisor

Customer Survey

Rate the cleanliness of your area.

Rate the responsiveness of our staff to your requests.

Rate the availability of restroom and patient area supplies.

Quality Tour Comments

Patient Room 1

Patient Room 2

Patient Room 3

Med Room

Nurses Station

Staff Lounge

Staff Restroom

Clean Utility Room

Soiled Utility Room

Family Waiting Room

Family Waiting Room RR

Corridors

Computer Room

Elevators

Stairwells

Comments

Completion
Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.