For each item, mark the response that best matches your opinion.

* Date

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* Location

* Program (Select One)

* Architecture

  Strongly Agree Agree Disagree Strongly Disagree N/A
1. I have had no difficulty in accessing the facility, including sidewalks, ramps, and exterior doors.
2. All sidewalks to the facility have curb cuts and are compliant with the 36" wide requirement.
3. All ramps are compliant with ADA requirements, painted, and have nonslip strips on every ramp.

* Environment

  Strongly Agree Agree Disagree Strongly Disagree N/A
4. The temperature in the facility is appropriate for my needs.
5. Administrative offices are soundproof to the extent that privileged conversation cannot be heard by others.

* Attitudes

  Strongly Agree Agree Disagree Strongly Disagree N/A
6. Input through satisfaction surveys and other forms of communication are solicited by the organization.
7. The staff has extensive knowledge and understanding of the treatment issues.

* Finances

  Strongly Agree Agree Disagree Strongly Disagree N/A
8. As a client of this organization, I believe that the fees requested are justified.

* Communication

  Strongly Agree Agree Disagree Strongly Disagree N/A
9. Multilingual staff are available to work with persons where English is not their primary language.
10. Telecommunication devices are available to visual or hearing impaired individuals.
11. Documents are available and written in languages or formats that is understood by the client / employee of this organization.

* Transportation

  Strongly Agree Agree Disagree Strongly Disagree N/A
12. I have transportation available to me to participate in the full range of services or activities of the organization.

* Community Integration

  Strongly Agree Agree Disagree Strongly Disagree N/A
13. The organization has worked to eliminate or limit any barrier that might keep me from returning to full participation in my community.
14. I am able to participate in community activities of my choice.

* Overall Satisfaction

  Strongly Agree Agree Disagree Strongly Disagree N/A
15. Overall, this organization's staff treat persons well.
16. I would recommend this organization to a person in need of these services.

* Comments:

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