This questionnaire includes open-ended questions and scale response questions.

To answer the scale response questions, please read each statement and select the response that best matches your opinion. Your choices range from:

1= Strongly Disagree......6= Strongly Agree

It should take you no more than 10 minutes to complete the questionnaire.

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* 1. What type of facility/agency are you? (Provider type)

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* 2. What type of on-site visit was performed?

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* 3. Did the on-site visit identify deficient practices?

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* 4. If yes, were the majority of the deficient practices cited valid?

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* 5. The on-site visit provided an opportunity to identify areas for improvement.

  1 Strongly Disagree 2 3 4 5 6 Strongly Agree
Please rate your level of agreement.

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* 6. The reason for the on-site visit and overview of the process to occur was clear and complete.

  1 Strongly Disagree 2 3 4 5 6 Strongly Agree
Please rate your level of agreement.

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* 7. Rate the tone/tenor of the on-site visit.

  1 Strongly Disagree 2 3 4 5 6 Strongly Agree
Respectful
Collaborative
Solution-Oriented

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* 8. The purpose of the on-site visit and the initial requests for documentation were clear during the entrance process.

  1 Strongly Disagree 2 3 4 5 6 Strongly Agree
Please rate your level of agreement.

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* 9. An opportunity was provided at the end of the on-site visit to ask questions and receive answers.

  1 Strongly Disagree 2 3 4 5 6 Strongly Agree N/A
Please rate your level of agreement.
Please provide your feedback to the following questions.

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* 10. Did a state employee stand out in professionalism and courtesy that you would like to recognize and commend? If so, please provide his/her name.

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* 11. Was there a state employee that could use additional training, etc., in your opinion and what areas or skills could we improve upon?

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* 12. What worked well during the on-site visit? What were the highlights?

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* 13. Are there opportunities for improvements in our on-site process and, if yes, what specifically could we work on?

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* 14. Do you have any additional comments?

Thank you for completing this questionnaire.

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