Activities Satisfaction Survey

1. Please enter your contact information (optional)

First Name
Last Name

2. Please tell us your relationship to the patient Required Question

3. Date of Response Required Question

4. How often do you participate in our group activities?

	Very often
	Often
	Occasionally
	Rarely or Never

5. Please rate your enjoyment of the following activities:

	1 Star = NOT ENJOYABLE, 3 Stars = NEUTRAL, 5 Stars = VERY ENJOYABLE
Music Programs
Games
Exercise and Stretching
Pre-Meal Activities in Dining Room
Arts & Crafts
Flower Arranging / Gardening
Spiritual Activities / Church
Room Visits
Cooking Activities

6. How do you feel about activities program?

	Better than Expected
	As Expected
	Less than Expected
	N/A

7. Were the Activities Staff friendly and helpful?

	Yes
	No
	N/A

8. Shortly after admission, were you orientated to the Activities program and made aware of the calendar posted in room & hallway?

	Yes
	No
	N/A

9. QOL: Have the Activities staff provided you with access to leisure items at bedside such as books, magazines, word puzzles, etc?

	Yes
	No
	N/A

10. QOL: Have your spiritual needs been acknowledged and maintained? (such as privacy for prayer or meditation, TV or radio available, assistance to attend spiritual services, visitor and support provided)

	Yes
	No
	N/A

11. What did you like best about our activities program?

12. Any suggestions on how we could improve our activities?