Family Satisfaction Survey

Thank you for working with RSVP, Inc. Your satisfaction with our services is of the utmost importance. We welcome your feedback and suggestions.

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1. Please enter the Consumer's Name (Required.)

Consumer's Name

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2. Please enter your name and your relationship to the consumer (Required.)

My Name

Relationship to Consumer

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3. Please enter the RSVP, Inc. Specialist's Name (Required.)

RSVP, Inc. Specialist's Name

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4. Please select the current service status: (Required.)

Initial

Ongoing

Follow-Along

Case Closure

Please select the most appropriate response to the following statements.

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5. The consumer had input when making a job choice. (Required.)

False

Somewhat False

Uncertain

Somewhat True

True

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6. The consumer was helped to get ready to work in the community. (Required.)

False

Somewhat False

Uncertain

Somewhat True

True

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7. The consumer has learned new job skills. (Required.)

False

Somewhat False

Uncertain

Somewhat True

True

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8. The consumer's job goal fits his/her interests. (Required.)

False

Somewhat False

Uncertain

Somewhat True

True

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9. The consumer has reliable transportation. (Required.)

False

Somewhat False

Uncertain

Somewhat True

True

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10. Family members are treated with respect by RSVP, Inc. staff. (Required.)

False

Somewhat False

Uncertain

Somewhat True

True

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11. The consumer is safe in the community. (Required.)

False

Somewhat False

Uncertain

Somewhat True

True

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12. The consumer has identified a salary goal. (Required.)

False

Somewhat False

Uncertain

Somewhat True

True

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13. The consumer enjoys the job preparation/development process. (Required.)

False

Somewhat False

Uncertain

Somewhat True

True

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14. Family members like working with RSVP, Inc. staff. (Required.)

False

Somewhat False

Uncertain

Somewhat True

True

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15. The consumer receives SSI/SSDI disability benefits? (Required.)

Yes

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16. The consumer is able to maintain SSI/SSDI disability benefits? (Required.)

Yes

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17. The consumer is able to maintain Medicaid (SSI), Medicare (SSDI), or other health benefits? (Required.)

Yes

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18. The consumer receives Medicaid (SSI), Medicare (SSDI), or other health benefits? (Required.)

Yes

Family Satisfaction Survey

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* 1. Please enter the Consumer's Name (Required.)

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* 2. Please enter your name and your relationship to the consumer (Required.)

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* 3. Please enter the RSVP, Inc. Specialist's Name (Required.)

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* 4. Please select the current service status: (Required.)

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* 5. The consumer had input when making a job choice. (Required.)

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* 6. The consumer was helped to get ready to work in the community. (Required.)

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* 7. The consumer has learned new job skills. (Required.)

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* 8. The consumer's job goal fits his/her interests. (Required.)

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* 9. The consumer has reliable transportation. (Required.)

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* 10. Family members are treated with respect by RSVP, Inc. staff. (Required.)

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* 11. The consumer is safe in the community. (Required.)

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* 12. The consumer has identified a salary goal. (Required.)

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* 13. The consumer enjoys the job preparation/development process. (Required.)

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* 14. Family members like working with RSVP, Inc. staff. (Required.)

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* 15. The consumer receives SSI/SSDI disability benefits? (Required.)

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* 16. The consumer is able to maintain SSI/SSDI disability benefits? (Required.)

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* 17. The consumer is able to maintain Medicaid (SSI), Medicare (SSDI), or other health benefits? (Required.)

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* 18. The consumer receives Medicaid (SSI), Medicare (SSDI), or other health benefits? (Required.)

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* 19. The consumer has out-of-pocket disability-related work experiences (i.e., transportation, medications, supplies, etc.)? (Required.)

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* 20. Things I like about the services/outcome: (Required.)

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* 21. Things I do not like about the services/outcome: (Required.)

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* 22. Date Survey Completed (Required.)

1. Please enter the Consumer's Name (Required.)

2. Please enter your name and your relationship to the consumer (Required.)

3. Please enter the RSVP, Inc. Specialist's Name (Required.)

4. Please select the current service status: (Required.)

5. The consumer had input when making a job choice. (Required.)

6. The consumer was helped to get ready to work in the community. (Required.)

7. The consumer has learned new job skills. (Required.)

8. The consumer's job goal fits his/her interests. (Required.)

9. The consumer has reliable transportation. (Required.)

10. Family members are treated with respect by RSVP, Inc. staff. (Required.)

11. The consumer is safe in the community. (Required.)

12. The consumer has identified a salary goal. (Required.)

13. The consumer enjoys the job preparation/development process. (Required.)

14. Family members like working with RSVP, Inc. staff. (Required.)

15. The consumer receives SSI/SSDI disability benefits? (Required.)

16. The consumer is able to maintain SSI/SSDI disability benefits? (Required.)

17. The consumer is able to maintain Medicaid (SSI), Medicare (SSDI), or other health benefits? (Required.)

18. The consumer receives Medicaid (SSI), Medicare (SSDI), or other health benefits? (Required.)

19. The consumer has out-of-pocket disability-related work experiences (i.e., transportation, medications, supplies, etc.)? (Required.)

20. Things I like about the services/outcome: (Required.)

21. Things I do not like about the services/outcome: (Required.)

22. Date Survey Completed (Required.)