Name First Name Last Name Do you get up in the morning when you want without being disturbed by staff? Yes No What time do you get up? What time would you like to get up in the morning? Do you go to bed at night when you want without the time being dictated by staff? Yes No What time do you go to bed? What time would you like to go to bed? Do you choose your own bath or shower schedule? How many times a week do you get a bath or shower? How many times a week would you like to bathe? Do you decide on your own whether to take a shower, whirlpool, bath, or sponge bath? What type of bathing are you receiving? What would you like to receive? Do you feel you can have visitors anytime it's convenient for you? Yes No Do you feel there are restrictions on visiting hours? Yes No Do staff treat you with respect and dignity? Yes No Tell us some examples about when staff did not treat you with respect and dignity. Do you participate in the activity programs here? Why is that? Do the activities meet your interests? Strongly Disagree Disagree Neutral Agree Strongly Agree Are the activities provided as often as you would like, including on weekends and evenings? Strongly Disagree Disagree Neutral Agree Strongly Agree Do you have items in your apartment that you use to entertain yourself when there are no activities to your liking? Yes No Thank you!
