National Consumer Voice

1. Have you been able to visit with your loved one?

Yes, the facility has allowed me to visit with my loved one inside the facility.
Yes, the facility has allowed me to visit with my loved one outside the facility.
No.

Where was the visit conducted?

In my loved one's room.
In a designated area.
Other

Please explain

Did the facility give you the option of a visit inside the facility?

Yes, but we chose to meet outside.
No, the facility did not give us the option of meeting inside.

What reason did the facility give you for not allowing you to visit inside the facility?

What reason did the facility give your for not allowing you to visit with your loved one?

2. Did the facility require you to schedule a visit with your loved one?

Yes
No

3. Did the facility require you to show documentation that you had received a COVID-19 vaccination, in order to visit with your loved on?

Yes
No

4. Did the facility require that you be tested for COVID-19 prior to visiting?

Yes
No

Did the facility provide testing on site?

Yes
No, the facility required me to obtain a test myself.

5. Did the facility require that you wear personal protective equipment (PPE) such as masks or gowns?

Yes, the facility provided me with PPE.
Yes, but the facility required me to provide my own PPE.
No requirement to wear PPE.

6. Was the visit private?

Yes
No

Why not?

7. Did the facility allow you to touch (hold hands, hug) your loved one?

Yes
No

What explanation, if any, did the facility provide why touch was prohibited?

8. Did the facility place a time limit on the length of your visit?

Yes
No

How long did the facility allow you to visit with your loved one?

9. Has the facility limited how often you can visit your loved one?

Yes
No

How often is the facility allowing you to visit?

10. Is the facility limiting the number of people who may visit at one time?

Yes
No

How many visitors is the facility allowing at one time?

11. Did there appear to be sufficient staff to meet residents' needs?

Yes
No

12. If you had problems visiting your loved one, did you file a complaint with your state agency that oversees and inspects nursing homes?

Yes
No
I did not have problems visiting my loved one.

What was the response?

Complaint was substantiated.
Complaint was not substantiated.
No response.

13. Please share with us anything else you think we should know about your visitation experience.

14. If you are comfortable sharing the state in which your loved one resides, please do so below. We will never share any of your information without your permission.

15. May we share your responses in our advocacy to ensure residents' rights to visitation are enforced? We will never use any information that could identify you or your loved one.

Yes
No

16. If you are comfortable sharing your name and contact information, please do so below. We will never share any of your personal information, without your permission.

First Name

Last Name

Email

Phone

Area Code

Phone Number

Please tell us about your visitation experiences with your loved ones