Catholic Charities Customer Questionnaire Question Title * 1. Survey Date Date / Time Date Question Title * 2. Program Name A Gathering Place Apollonia Guild Chautauqua Outreach-Client Chautauqua Outreach-Volunteer Closing the Gap Community Health Worker Comprehensive Care CORE Counseling-FACS Diocesan Counseling Center Domestic Violence program for Men Emergency Assistance Emergency Stabilization-City of Buffalo Emergency Stabilization-City prevention Emergency Stabilization-Erie County Encompass Children’s Health Home Food Pantry Foster Grandparents Program Friendly Phones Guild for the Blind Home Visitation Program Immigration Services Incredible Years-Preventive Incredible Years-Private Pay In School Social Work Program Job Development for LEP Jump Start Kinship Caregivers Kinship Preventive Services Ladies of Charity-Volunteers Ladies of Charity-Referrals Ladies of Charity-Store MCI-Humboldt Clinic MCI-Lockport Clinic MCI-Marriage Counseling MCI-NF Clinic MCI-NT Clinic MCI-Rich St. Clinic Monitored Exchange MST-Preventive MST NYSESRP NFESPRI Nutritional Education OASAS Our Kids-PEAP Parent/Child Access PC (Medical Case) Project HOPE Reception & Placement Refugee Health Promotion Refugee Preventive Services Refugee Social Services Program Telephone Assurance Program TYT-Erie Traditional Preventive Services-Erie TSV United Works Unknown WIC Women’s Healing and Empowerment Services Wyoming Outreach-Client Young Parent Question Title * 3. Program Location Albion Amherst/St. Bens Batavia BPS Broadway-Bailey Catholic School Cheektowaga Diocesan Counseling Dunkirk Franklinville District Office Franklinville Pantry Fulton Pantry Genesee St Hamburg Herkimer Humboldt IRAP (church) IRAP (school) Jamestown Kenfield/East Side Kenmore Lackawanna Ladies of Charity Lockport Lovejoy Pantry Main Office/Downtown Marriage Counseling North Tonawanda Off-Site Olean Perry Rich St. S. Buffalo Pantry Town Square Pantry Tronolone Wellsville WIC Springville WIC Harlem Road WIC North Tonawanda WIC Dunkirk WIC East Aurora WIC Northwest Comm Center WIC Sherman WIC Silver Creek WIC Sister’s Hospital WIC South Buffalo WIC Grant Street WIC Tuscorora WIC Lockport WIC Westfield Wilson (St. Stan’s) Workforce Development Question Title * 4. How likely are you to recommend our program to a friend, family member or colleague? 1 Not at all likely 2 3 4 5 6 7 8 9 10 Very likely 1 Not at all likely 2 3 4 5 6 7 8 9 10 Very likely Question Title * 5. If you rated us from 0 to 6, we apologize for not meeting your expectations. What did we not do or is there something we could do to improve? Question Title * 6. If you rated us a 7 or an 8, thank you. Could you share what we could do to raise the rating to a 9 or a 10? Question Title * 7. If you rated us a 9 or 10-Great! Could you share what we are doing and should continue to do? Question Title * 8. How would you rate the quality of the service you received? 1 Poor 2 3 4 5 6 7 8 9 10 Excellent 1 Poor 2 3 4 5 6 7 8 9 10 Excellent Question Title * 9. The following data is for demographic purposes only: Question Title * 10. Your Age Question Title * 11. Gender Male Female Other Question Title * 12. What is your race or ethnicity? White Black Native American/Alaska Native Native Hawaiian Filipino Samoan Mexican Puerto Rican Cuban Other Hispanic/Latino Chinese Japanese Asian Indian Korean Vietnamese Other Asian Other Pacific Islander Multi-Racial Other Self-describe below: Question Title * 13. When did you first use the services of this program Within 1 month Within 1 year 1 year + Question Title * 14. Please check if either applies I want to speak to someone about the services I received. I would be willing to share the story of my experience with Catholic Charities for our annual Appeal or other media opportunities. Question Title * 15. Preferred way to contact Question Title * 16. Contact Information Done