Thank you for your recent call/visit to CJE SeniorLife’s Consumer Assistance department. Your satisfaction with this program is very important to us. Please take a few minutes to fill out this survey. Your responses will help us understand what works and what areas may need improvement. Your responses will be completely anonymous unless you choose to provide us your information at the end of the survey.

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* 1. Participant ID

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* 2. 1. In the last six month, I received help from CJE SeniorLife’s Consumer Assistance department about: (check all that apply)

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* 3. I spoke with a CJE SeniorLife Consumer Assistance staff member:

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* 4. I received service from a CJE SeniorLife Consumer Assistance staff member at the following location(s) (check all that apply):

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* 5. Please check off how much you agree or disagree with the following statements based on a scale of 1 to 5, with 1 being Strongly Agree, and 5 being Strongly Disagree:

  Strongly Agree (1) Agree (2) Neutral(3) Disagree (4) Strongly Disagree (5) Does Not Apply (6)
2. Overall, I was satisfied with my experience with CJE SeniorLife Consumer Assistance.
3. Based on my experience with CJE SeniorLife Consumer Assistance, I feel an increased connection with the community and/or friends.
4. It was important to receive services within a faith-based context.
5. I would recommend CJE SeniorLife Consumer Assistance to a friend or family member.
6. It was easy to find the information I needed about CJE SeniorLife Consumer Assistance service.
7. It was easy to physically access CJE SeniorLife Consumer Assistance (including location, building, layout, etc.).
8. CJE SeniorLife Consumer Assistance staff were open to hearing and responding to my questions and concerns.

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* 6. As a result of getting services from CJE’s Consumer Assistance department, I: (check all that apply)

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* 7. Please check off how much you agree or disagree with the following statements based on a scale of 1 to 5, with 1 being Strongly Agree, and 5 being Strongly Disagree.

As a result of getting services from CJE SeniorLife’s Consumer Assistance department, I felt:

  Strongly agree Agree Neither agree nor disagree Disagree Strongly Disagree Does Not Apply
Less worried about the issue I called/visited about.
More confident that I can make progress on the task.
Less confused.
More hopeful about the future.
More knowledgeable about community resources.
More financially stable.
Better able to solve similar problems myself.
Confident that I know who to call when I have a future problem.
Optional:

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* 8. 1. Please circle—Age:

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* 9. 2. Please circle—Religious Affiliation:

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* 10. 3. Please circle all that apply—Race Ethnicity:

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* 11. 4. Please circle—Current Gender Identity:

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* 12. What is your zip code?

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* 13. If you’d like to be contacted, please provide the following information:

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* 14. Comments:

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