Nursing Home Safety Questionnaire

At [Your Company Name], our priority is to ensure the highest safety standards in nursing homes. We believe in continuous improvement and understand that valuable insights come from those who interact with nursing homes closely. This questionnaire is designed to gather your experiences and perceptions regarding the safety measures within the nursing home industry. Your participation is crucial in helping us enhance the quality of care and safety for our residents.

Instructions:

Please take approximately 10 minutes to complete this survey.
Read each question carefully and select the most appropriate answer. For questions that require a detailed response, please use the space provided to elaborate as much as possible.
Answer every question to the best of your knowledge and belief.
Your responses will remain confidential and will be used solely for improving safety standards.
For questions requiring a scale rating, please use the following scale:

1: Very Poor / Not Confident At All

2: Poor / Slightly Confident

3: Average / Moderately Confident

4: Good / Confident

5: Excellent / Very Confident

Section	Question	Options/Response
General Information	1. What is your relationship to the nursing home resident(s)?	Family member Friend Legal Guardian Other, please specify:
	2. How long has the resident been in this nursing home?	Less than 1 year 1-2 years 3-5 years More than 5 years
Facility Safety	3. Have you observed any safety hazards in the nursing home environment?	Yes No If yes, please describe:
	4. How would you rate the overall safety conditions at the nursing home?	Scale 1-5:
Fire Safety and Emergency Procedures	5. Does the nursing home have clearly marked emergency exits?	Yes No Not sure
	6. Are there regular fire drills in the nursing home?	Yes No Not sure
	7. How confident are you in the nursing home’s ability to handle emergencies?	Scale 1-5:
Infection Control and Resident Health	8. How would you rate the cleanliness of the nursing home?	Scale 1-5:
	9. Have there been any cases of contagious illnesses in the nursing home that you know of?	Yes No Not sure If yes, please specify:
	10. Do you believe that the administration conducts regular health audits or checkups for residents?	Yes No Not sure
Staff Behavior and Training	11. How would you rate the professionalism and behavior of the staff?	Scale 1-5:
	12. Do you think the staff is well-trained to handle medical emergencies?	Yes No Not sure
Security Measures	13. Does the nursing home have an access control system?	Yes No Not sure
	14. Do you feel that the resident's belongings and valuables are secure?	Yes No Not sure
	15. How confident are you in the overall security measures of the nursing home?	Scale 1-5:

Thank you for dedicating your time and providing us with valuable feedback. Your insights are essential for us to ensure the safety and well-being of our nursing home residents. Should you have any further comments or wish to discuss any of your responses, please do not hesitate to contact us.

Prepared by: [YOUR NAME]
Company: [YOUR COMPANY NAME]
Date: [DATE]