Questions: Please read each question below (#1-10) related to the services you received at the Center and then select the response that best represents your answers. The scale ranges from (strongly disagree) to (strongly agree).

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* 1. The staff and I were able to communicate clearly.

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* 2. The staff had a positive attitude while working with me.

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* 3. The staff treated me respectfully.

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* 4. In most cases, staff responded back to me in a timely manner.

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* 5. I had an opportunity to set my goals.

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* 6. I can make my own decisions at the Center for Independent Living.

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* 7. The help that I received from the Center for Independent Living made me feel more confident about being able to deal with my life.

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* 8. I improved my ability to live independently in the community as a result of services I received at the Center.

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* 9. I am satisfied with the services that I received at the Center.

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* 10. I would recommend the Center to others.

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* Please provide any additional comments below:

II. Demographics: Please check the appropriate responses for your demographic background to help us to better understand the diversity of the services provided to the network.

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* A. What is your gender: (Select one)

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* B. What age group are you in? (Select one)

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* C. What ethnic group do you belong to or identify with? (Select one)

SELECT ALL THAT APPLY BELOW:

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* COGNITIVE:

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* PHYSICAL:

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* MENTAL:

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* SENSORY:

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS SURVEY
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