Interior Designer Questionnaire

The purpose of this survey of VA interior designers is to establish a

profile in order to network and strengthen the interior design program.

Background:

Name__________________________________________________

Facility_________________________________________________

Address________________________________________________

_______________________________________________________

Telephone No. _________________ FAX _____________________

E-mail address __________________________________________

Title___________________________________________________

Grade__________________________________________________

Years in design_______ Govt._______ Non-Govt.____________

Other VA facilities you have work at _________________________

Education______________________________________________

Professional Affiliations____________________________________

Tell something you like to do or a special hobby ________________

_______________________________________________________

Your Facility

What area of care does your facility provide?

Acute/Intermediate/Long -Term, Nursing Home/Hospice /Dementia

Psych/Substance Abuse/Spinal Cord/ Other such as a

Hoptel/Women's Clinic etc.

_______________________________________________________

Do the interior designers at your VISN get together/plan

together/share services/have furniture or equipment exchanges/any