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Thank you for agreeing to take part in the Food Service Satisfaction Questionnaire for individuals who have a family member living in an aged care home. This questionnaire asks you about your satisfaction with the food service that your family member receives in their aged care home. In this questionnaire, food service is defined as the provision, serving and preparation of food or meals.
For each item in the questionnaire, please select which answer best describes how true each statement is for you. There is also a section at the end of the questionnaire where you can write any additional thoughts or comments in your own words, if you wish to. This questionnaire should take around 20 minutes to complete. Be assured that your responses will remain anonymous. You do not have to complete this questionnaire if you decide that you do not want to.
First, we would like to ask you some questions about yourself and your family member.
What is today's date? (dd/mm/yyyy)
Date
Are you:
Male
Female
Non-binary / third gender
Prefer not to say
Please indicate your age by choosing one choice below:
18-21 years
21-30 years
31-40 years
41-50 years
51-60 years
61-70 years
70+ years
Please tell us about your family member that is permanently living in residential aged care?
Age
Gender
Relationship to you
What is the name of the aged care home they are currently living in? (This information will remain confidential and is only used for the purpose of statistical analysis)
Approximately how long have they lived in that home?
Have they lived in any other home previously?
On average, how often do you communicate with your family member (e.g. by phone, email)?
Daily
Daily - Weekly
Weekly - Monthly
Every three months
Every six months
Yearly
On average, how often do you visit your family member in the aged care home? (e.g. once per week, twice a month)
Does your family member have any special diet requirements?
No
Yes, please specify:
Texture modified
Diabetes
Gluten Free
Other, please specify:
Does your family member have any form of cognitive impairment or dementia?
Yes
No
Unsure
What is your postcode?
This questionnaire should be completed from your own personal perspective based on your experiences and observations in the aged care home. Please click next to continue.
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