Please keep in mind the information that you provide in this survey is CONFIDENTIAL. Please be aware that your opinion and responses are very Important to help improve the program. Please read the following statements and check the most appropriate response based upon the past 6 months of individual's employment. Thank you.

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* 1. Job Coach:

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* 2. Job Developer:

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* 3. Date Employed:

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* 4. Date Survey Completed:

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* 5. Goodwill is helping me to achieve my employment goals.

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* 6. Goodwill staff helps me to learn new employment skills.

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* 7. Goodwill staff is sensitive to my ethnic, religious, and cultural background.

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* 8. I am treated with dignity and respect by Goodwill staff.

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* 9. Goodwill helps me to feel safe and comfortable at work.

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* 10. I am given opportunity to make choices by Goodwill.

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* 11. Overall I am satisfied with the supported employment services I received from Goodwill.

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* 12. How likely are you to recommend Goodwill to others who need supported employment services?

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Please rate on a scale of 1 to 10, with 10 being the most likely to refer others.

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* 13. Things I like best about this provider are:

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* 14. Things I'd like to see improved are:

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* 15. Additional comments:

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