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FY2026 Client Satisfaction Survey
*
1.
Mark all services your household got from our agency within the last 12 months:
(Required.)
LIHEAP/Heating Help
Food Pantry
Hygiene Assistance
WIC
Head Start
Early Head Start
General Information/Referral
Furnace Repair/Replace
Clothing Assistance
FaDSS (Family Development and Self Sufficiency)
Housing or Rent Assistance
Emergency Utility
Senior Home Repair
Weatherization
None
Other (please specify)
2.
I got the information and services I needed:
Yes
No
N/A
Comments
3.
Additional program/service I would like Community Action to offer:
4.
I had a positive experience when receiving services:
Yes
No
N/A (Does not apply)
Comments
5.
I was informed about other agency or community services:
YES
NO
N/A (Does not apply)
6.
Are there any problems or needs you or your family faced within the last 12 months you were unable to get help with?
Yes (please list below)
No
If Yes please list those problems or needs
7.
What are the greatest challenges your household is currently facing? (Check all that apply)
Employment
Livable Wage Job
Keeping a Job
Getting food
Food Budgeting
Getting Hygiene Items (feminine products, diapers, soaps, etc)
Physical Health
Mental Health
Getting Medical Care
Health Care Costs/Bills
Budgeting
Debt
Payday Loans
Housing
Transportation
Adult Education/Training
Child Education
Safety
Legal Issues
Abuse
Substance Use
Finding Childcare
Paying for Child Care
Child Care During Hours Needed
Other (please specify)
8.
What is one suggestion you have for Community Action to improve on?
9.
How has Community Action made a difference in your life?
10.
What county do you live in?
Des Moines
Henry
Lee
Louisa
Muscatine
Washington
Other (please specify)
11.
Date
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
12.
Optional: Would you be willing to share your story?
Yes
No
13.
Optional: If you're willing to share your story, please provide your contact information.
Name
Email Address
Phone Number
14.
Optional: Other Comments
Current Progress,
0 of 14 answered
