Your name:

Course # and section:

Date:

Name of agency or facility:

Address and location:

Name of contact person:

Title:

Telephone number:

Summary description of agency or facility:

History of facility (when established, etc.):

What is goal of facility or Mission Statement of facility?

Scheduled activities / recreation / events?

Inpatient (residential) or outpatient (day care)?

Number of residents or clients:

Number of beds or rooms:

Special rooms, facilities, etc. (e.g. exercise rooms, eating rooms, dining rooms, cafeterias, day rooms, meeting rooms, etc.)

Funding for facility.  Public or private?  Government?  County, State, Federal?

Costs to clients:

Sliding fee scale?

How do most clients pay?  Medicare, medical insurance, private pay, etc

Number of staff:

Education and Training of staff:

What is your general impression of this facility?  Describe and discuss any other aspects of the agency or facility that are important or that made a particular impact on you.

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