Describe any instances where staff: 

• Made you feel afraid or humiliated/degraded  

• Said mean things to you 

• Hurt you (hit, slapped, shoved, handled you roughly) 

• Made you feel uncomfortable (touched you inappropriately) 

• Have you seen or heard of any residents being treated in any of these ways? 

• Did you tell anyone about what happened (e.g., staff, family, or other residents)? What was their response?  

NOTE: If you receive an allegation of abuse, immediately report this to the facility administrator, or his/her designated representative if the administrator is not present. 

If the concern is dignity related, mark dignity as Further Investigation.