Archit Home Health Care – Feedback Form Name of Elderly (Mr/Mrs/Smt) Age Sex MaleFemaleOther Address Services Taken Of Name of Service / Caretaker / Nursing Staff Service Period Feedback Points 1) Reporting on Time PoorAverageGoodVery GoodExcellent 2) Cleanliness PoorAverageGoodVery GoodExcellent 3) Work Performance PoorAverageGoodVery GoodExcellent 4) Attentiveness PoorAverageGoodVery GoodExcellent 5) Any Other Complaints If you have to give grading: 1 = Poor | 5 = Good | 8 = Satisfactory | 10 = Excellent Overall Grade Remarks Name of Person Giving Feedback Mobile Number I confirm the above feedback is true to the best of my knowledge.
