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1. Purpose

In an effort to continually improve our services WJS regularly surveys parents, family members, friends, advocates, funders, case managers, caregivers, guardians,and others who are involved with the individuals who are receiving services in our programs.

By taking the time to fill in our survey you are helping us to
* Find out what we're doing right;
* Find out what we could do better;
* Gather suggestions about ways we can improve services.

We appreciate your time in completing this survey!

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* 1. I am responding to this survey for the following program:

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* 2. I am a (please select one only):

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* 3. My level of overall satisfaction with the services provided by the program with which I am involved is:

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* 4. My satisfaction with the level of respect and courtesy with which I am treated by WJS staff is:

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* 5. I am ___________________ with my opportunity to provide input and feedback to the program as it relates to the individual(s) I represent.

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* 6. I am______________ that my concerns are dealt with in a reasonable amount of time.

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* 7. I am___________ with the program's response to any concerns I may have.

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* 8. I am _______________ with the information I receive about the individual I represent.

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* 9. I am________________ with the knowledge and skills of the staff I am in contact with.

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* 10. I am ____________ that the individual that I represent is valued, respected and treated with dignity by the program and it's staff.

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* 11. I am __________ that the individual that I represent is provided opportunities by the program to learn/practice useful skills.

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* 12. I am __________ that the individual I represent is provided opportunities by the program to improve and/or form new relationships.

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* 13. I am __________ that the program provides the individual I represent with opportunities for community involvement.

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* 14. I am __________ that the program does it's best to provide a safe and healthy place for the individual I represent.

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* 15. I am __________ that the program staff advocate for/look out for individuals receiving service and their families.

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* 16. I am __________ that the program encourages and supports the individual I represent to make decisions affecting themselves.

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* 17. I am __________ that the individual I represent is receiving service that meets their individual needs?

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* 18. I am __________ with the flexibility and responsiveness of the services at the program.

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* 19. What about the program are you particularly happy with?

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* 20. Is there anything you would change about the program?

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* 21. I have the following comments or suggestions:

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* 22. Do you want to talk to a senior manager about your experience with WJS?

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* 23. If you answered "yes" you want to speak to a senior manager, please provide the following:

Thank you for completing this survey. We use information from surveys such as this one to improve our service to the people we serve and our stakeholders, and your opinions are important to us.

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