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un Parlor Home C O U N T V O F E 5 5 E % RESIDENT FEEDBACK SURVEY Welcome to the Sun Parlor Home's 1s' Resident Feedback Survey! The completed survey can be mailed back in the envelope provided or you can drop it off in the Bank Mail Slot before Friday, February 14, 2014. Thank you for taking the time to complete this survey. Your feedback will help us improve the care and services we provide our residents. We value your opinions—whether they are positive or negative. We also appreciate any comments and suggestions. Rest assured that the answers to this survey will be treated confidentially and where applicable in accordance with the Personal Health Information Protection Act (PHIPA). Your name, room number and date of birth will not appear anywhere on this survey. All results will be collated by an independent analyst to maintain feedback integrity. Please complete only ONE of EITHER this paper version or the on-line version at https://www.surveymonkey.com/s/SPHResidentFeedbackSurvey20l4. If at any time, you would like to stop, or have something to say, please feel free to interrupt me. ANSWER KEY: Yes = MOST or ALL of the time Sometimes = SOME of the time, Not always No = RARELY or NEVER N/A = Question does not apply to you Don't Know= You don't have enough information to answer the question [VOLUNTEER INSTRUCTIONS: Unless otherwise indicated, if response is Sometimes/No, please ask resident to provide specific details in Comments section below the question.] 1. SURVEY COMPLETED BY ❑Resident ❑ Completed on Behalf of Resident (example: volunteers, students, staff, etc.) ❑ Completed by Family Member/Friend/Third Party RESIDENT ACTIVITIES YES SOMETIMES NO N/A DON'T KNOW 2. Do you participate in the activities offered by the home? ❑ ❑ ❑ ❑ ❑ 3. If NO, is this important to you? ❑ ❑ 4. Do the organized activities meet your interests? ❑ ❑ ❑ ❑ ❑ Resident Feedback Survey Page 1 of 6