Children's Services Evaluation Form: Group Homes/Child Caring Agency/Child Placing Agency

Dear Licensee or Director:

Time is important and so are your comments and suggestions. Please take this opportunity to tell us how we did on your most recent inspection/complaint investigation. The Nebraska Department of Health and Human Services (DHHS), Division of Public Health, asks your assistance in helping us evaluate and improve our inspection/complaint process. Your comments and suggestions are a vital part of our ongoing evaluation and improvement efforts.

To ensure confidentiality, the identity of the facility completing the survey is not disclosed to the inspector. However, if you choose to identify yourself and the facility for which you work, it will provide the Division of Public Health and/or Licensure Unit with an opportunity to seek your additional comments and suggestions about improving our process. Either way, your ratings and comments will be kept confidential.

We appreciate your candid responses and the opportunity to work with you on our shared goals of quality services for children and youth.
If you would like to be contacted please provide your name:
If you would like to be contacted, please provide your phone number (000-000-0000):
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Please click on your facility type:
Facility Type
Facility Name:
License Number:
Date of Survey/Inspection:
MM DD YYYY
Exit Date
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Please tell us the type of inspection or investigation (you may choose all that apply):
Please rate the Children's Services licensing staff's performance in the following areas:
Stongly AgreeSomewhat AgreeNeither Agree nor DisagreeSomewhat DisagreeStrongly DisagreeNot Applicable (NA)
1. Our staff explained the inspection or complaint process at the beginning of the visit.
2. Our staff provided sufficient explanation and assistance to complete the necessary forms.
3. During the inspection, you or your staff were informed of the information needed and given the opportunity to provide additional information relevant to the findings.
4. At the end of the inspection, our staff presented inspection findings clearly and concisely.
5. If differences arose during the inspection, they were resolved prior to our staff's departure.
6. Our staff were professional and courteous with you and your staff.
7. Our staff were professional and courteous with children/youth in your program.
8. Aside from the inspection/complaint investigation, we responded to your inquiries by satisfactorily answering your questions.
9. Aside from the inspection/complaint investigation process, we responded to your inquiries by returning phone calls in a timely manner.
If you would like us to contact you, be sure to enter your name and phone number in the boxes provided at the top of this page. If you have additional comments, please provide them in the box below. Thank you for completing this survey!
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