Focus Group-Facility Staff

Focus Group Participant Information Questionnaire
Facility Staff

Please complete this questionnaire. This information will be used only for summarizing participant information
at this meeting. Please DO NOT write your name or address on this questionnaire.
Date: ________________________

1. I am the:

Time: ________________________

__ Physician
__ Licensed Nurse
__ Nursing Assistant/Aide
__ Direct Care Staff (e.g., Dietician, Pharmacist, Social Worker)
__ Activities Directors/Staff
__ Other: ___________________________

2. I work in a:

__ Nursing home
__ Board and care home (assisted living, residential care, and other non-nursing home settings)
__ Other: ___________________________

3. I have been in this role for: _____ years _____ months
4. I am:

___ Male
___ Female

THANK YOU FOR YOUR HELP!
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