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* 1. Select your care setting:

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* 2. DSHS region

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* 3. Date(s) of full inspection/survey

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* 4. Number of citations (total) – identify in each area

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* 5. Experience with the surveyors/licensors

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* 6. Upload your SOD/2567

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 7. What went well with the survey/inspection process?

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* 8. What things could be improved based on your experience with the state agency staff and the survey/inspection process?

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* 9. OPTIONAL: May we contact you with questions? (If yes, complete information below)

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* 10. Other comments

For SNF Questions: Email Elena Madrid
For AL Questions: Email Vicki McNealley

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