Name of Patient^*

Age^*

Check All Services Received ^*

Gender^*

Race/Ethnicity^*

Staff arrives on time ^*

Referral/transfer was timely ^*

Missed visits recouped per my request ^*

Agency staff available 24 hours x 7 days ^*

Listened to you^*

Explain type of services you will be receiving ^*

You participate in decision making process^*

You are provided with written material as needed ^*

Staff is professionally dressed ^*

Staff respects my rights ^*

Staff demonstrates understanding of cultural diversity ^*

HHA provided quality care ^*

You can speak with office staff as needed ^*

Staff calls to explain schedule changes ^*

Staff is professional ^*

Would you refer your friends/family to MEIGER Health?^*

What do you like best about MEIGER Health? ^*

What do you like least about MEIGER Health? ^*

What suggestions do you have for improvement? ^*