Walton Community Services Inc. Member Satisfaction Survey

Question Title

* 1. Your Services are what you need or require

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 2. Your Services are provided in a timely manner. If you are receiving home services your Aid arrives on time

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 3. The duties or activities that you request are done as needed or required to assist you in your services

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 4. Your Staff that provides your services is responsive and know what your needs are

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 5. Staff arrive time to provide your services

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 6. Staff is culturally sensitive to your needs ( or know the needs of your culture and customs) to provide your services

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 7. Your food ( if meals are prepared) is of good quality

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 8. Your food ( if meals are prepared) is of a good temperature for hot /warm foods served by your staff

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 9. Your food ( if meals are prepared) is cold, for cold foods, drinks served by the staff

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 10. Staff respects your rights, choices, privacy, dignity, property, and protect you from harm and exploitation

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 11. Staff display a courteous attitude towards you

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 12. Are you please with your current Staff

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 13. Are you satisfied with your present Services

	Yes	No	Sometimes	N/A
Yes, No , Sometimes	Yes, No , Sometimes Yes	Yes, No , Sometimes No	Yes, No , Sometimes Sometimes	Yes, No , Sometimes N/A

Other (please specify)

Question Title

* 14. Does the Nurse Supervisor come to your home every two month( for persons receiving in home services)

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 15. Does the Administrative Personnel respond to your concerns timely

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 16. Does the Administrative Peronnel courteous, and treat you with dignity and respect when you call the office, etc.

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 17. Are your telephone calls returned promptly within 30 minutes for non -emergencies and 15 minutes for emergencies

	Yes	No	Somtimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Somtimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 18. Are your emails returned within 24 hours

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)

Question Title

* 19. Do you feel involved in your services

	Yes	No	Sometimes	N/A
Yes, No, Sometimes	Yes, No, Sometimes Yes	Yes, No, Sometimes No	Yes, No, Sometimes Sometimes	Yes, No, Sometimes N/A

Other (please specify)