Consumer Experience Survey

Your experience at Western New York Independent Living is our measure of success.

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* 1. Please identify the first and last name of the staff you worked with today:

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* 2. Please identify the Agency/Department you received services from today:

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* 3. Please let us know if your business today has been:

	Yes	No
TIMELY: Did we respond to your needs in a reasonable amount of time?	TIMELY: Did we respond to your needs in a reasonable amount of time? Yes	TIMELY: Did we respond to your needs in a reasonable amount of time? No
COURTEOUS: Was our interaction with you courteous and polite?	COURTEOUS: Was our interaction with you courteous and polite? Yes	COURTEOUS: Was our interaction with you courteous and polite? No
WELCOMING: Did you find our offices to be a clean, inviting, and safe environment?	WELCOMING: Did you find our offices to be a clean, inviting, and safe environment? Yes	WELCOMING: Did you find our offices to be a clean, inviting, and safe environment? No
ATTENTIVE: Did you find our staff attentive, alert and observant about your issues and concerns?	ATTENTIVE: Did you find our staff attentive, alert and observant about your issues and concerns? Yes	ATTENTIVE: Did you find our staff attentive, alert and observant about your issues and concerns? No
HONEST: Was our staff always truthful while conducting business with you?	HONEST: Was our staff always truthful while conducting business with you? Yes	HONEST: Was our staff always truthful while conducting business with you? No
OPEN: Was our staff accommodating with regard to your beliefs, ideas, goals, and perspectives?	OPEN: Was our staff accommodating with regard to your beliefs, ideas, goals, and perspectives? Yes	OPEN: Was our staff accommodating with regard to your beliefs, ideas, goals, and perspectives? No
EMPOWERING: Were you the decision maker at all times?	EMPOWERING: Were you the decision maker at all times? Yes	EMPOWERING: Were you the decision maker at all times? No
WILLINGNESS: Did our staff readily accept that you were in control of your goals and your chosen course of action?	WILLINGNESS: Did our staff readily accept that you were in control of your goals and your chosen course of action? Yes	WILLINGNESS: Did our staff readily accept that you were in control of your goals and your chosen course of action? No
PRODUCTIVE: Did you find your time here enhanced your ability to be successful in the completion of your goals?	PRODUCTIVE: Did you find your time here enhanced your ability to be successful in the completion of your goals? Yes	PRODUCTIVE: Did you find your time here enhanced your ability to be successful in the completion of your goals? No
FRIENDLY: Did you find our staff to be kind and pleasant to work with?	FRIENDLY: Did you find our staff to be kind and pleasant to work with? Yes	FRIENDLY: Did you find our staff to be kind and pleasant to work with? No

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* 4. Comments (optional):