Thank you for taking the time to complete this questionnaire developed to assist us in improving the services here at Central West Specialized Developmental Services (CWSDS). Your Feedback is very important as it helps us to shape our service to better meet the needs of the individuals we support and their families.

The survey should take 5 to 10 minutes to complete & your responses are completely anonymous.

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* 1. I am satisfied with the respite Program meeting my family needs for Respite.

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* 2. I am satisfied with opportunities to communicate with the Respite staff members.

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* 3. I am kept apprised of changes in my family member's health and well-being.

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* 4. I am satisfied with my family member's participation in programs and activities within the home and the community during their Respite visit.

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* 5. The home is inviting, comfortable and safe.

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* 6. I am satisfied with the level of care my family member receives.

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* 7. The Respite Report given to me at the end of the visit contains the right amount of information about the visit.

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* 8. Overall, how satisfied are you with the supports and services provided at Respite Program?

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* 9. Do you have any additional comments?

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* 10. If you would like to be contacted or speak to a member of the Quality Improvement Committee or any staff at CWSDS please provide your contact information.

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* 11. Yes, I would like (name of specific staff you would like to speak with) to contact me.

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* 12. Name (Optional unless you wish to be contacted)

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* 13. Telephone Number (Optional unless you wish to be contacted)

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* 14. E-Mail Address (Optional unless you wish to be contacted)

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