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1. Purpose

The people who provide the program that you are/have been involved in want to know what you think of your experience. We want to find out what we're doing right and what we could do better, and to learn from you how we can improve our overall service. We thank you for completing this survey.

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1. I am filling this out

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2. I go to ____________________________________ program?

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3. I am_________________________________________ with the services provided by the program.

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4. I am __________________________ treated with respect and courtesy by staff?

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5. I am _________________________________ able to share my thoughts with staff about the way the program affects me.

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6. When I have problems, staff ________________________ help me with them?

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7. I ___________________________ feel like the staff care about me?

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8. The program _________________________________ helps me learn things that will help me.

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9. I am ______________________ happy with the activities I participate in.

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10. I am ____________________________ happy with my level of involvement in activities away from the program.

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11. I ____________________________ friends in the program.

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12. I _________________________ feel safe and healthy at the program.

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13. I _________________________ get the chance to make decisions about things that affected me.

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14. I __________________________ get to have things I particularly want or need at the program.

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15. My favorite things about the program are:

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16. What I didn't like about the program is:

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17. Comments or suggestions:

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

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19. If you answered "yes" to question 18, what do you want to talk about?

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20. If you answered "yes" to #18, please provide your:

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Thank you for completing this survey. Your answers are important to us and give us information to help make our programs better for you and others!

Thank you for completing this survey. Your answers are important to us and give us information to help make our programs better for you and others!

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