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Thank you for taking the time to tell Blue Valley Community Action (BVCA) Partnership how we are doing so that we can provide the best services possible to meet your needs.

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* 1. Program or Service:

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* 2. County

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* 3. Overall, how would you rate the quality of services received as part of this program?

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* 4. To what extent have the services provided through this program met your needs?

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* 5. Did staff members offer you additional information about other programs that might help you and your family?

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* 6. How would you rate staff members’ knowledge of BVCA Partnership’s programs and services?

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* 7. Please mark your level of agreement or disagreement with the following statements:

  Strongly agree Agree somewhat Disagree somewhat Strongly disagree
Staff members treat me with respect.
I feel welcome when I visit the facility.
The facility is clean and comfortable.
Because of BVCA Partnership’s help, I have improved my situation.

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* 8. Would you recommend this program or service to others?

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* 9. How did you hear about this program or service? (Select all that apply.)

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* 10. What does your family struggle with the most?

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* 11. What is the primary language spoken in your home?

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* 12. What is your age?

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* 13. What is your gender?

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* 14. Are you Hispanic or Latino?

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* 15. What is your race? (Select all that apply.)

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* 16. If you have anything else you want us to know, please use the space below.

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* 17. If you wish to be contacted, please provide your name & contact information below.

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