INW Customer Satisfaction and Feedback Survey

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* 1. Please enter the four-digit code you received. (Check the mailer we sent you for a purple sheet - it's printed in bold in the center of the page.)

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* 2. Who is completing this survey?

INW customer

INW customer with help from a trusted family member

INW customer with help from a trusted friend

INW customer with help from a trusted provider

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* 3. Who is your Personal Agent at Independence Northwest?

Adrienne Akin

Andrea Ochsner

Angie Frank

Bernice Celino

Carl Fischer

Chris Psota

Clover Mow

Emily Dinwiddie

Jamie Osborn (formerly Jamie Lyzell)

Jenna Holt

Jesse Raposa

Jessica Kral

Joe Connell

Rondi Grace

I'm Not Sure

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* 4. Do you get the supports you need from INW?

Yes

Sometimes

Don't Know

Prefer Not to Answer

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* 5. How often do you communicate with your Personal Agent?

More than once a week

About once a week

A couple times a month

Monthly

Quarterly

Other (please specify)

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* 6. Due to the pandemic, we can't meet face to face. During this time, what's your preferred way of connecting with your Personal Agent?

On video chat (such as Zoom, Google Hangouts, Messenger, etc.)

On the phone

Through email

Through texting

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* 7. Are you happy with how often your Personal Agent connects with you?

Yes

No - I'd like to communicate MORE often

No - I'd like to communicate LESS often

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* 8. When you need help making decisions, does your INW Personal Agent help you?

Yes

Sometimes

Don't Know

Prefer Not to Answer

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* 9. One of the primary aims of Independence Northwest is to help you get connected to the supports you need. Are there unmet needs you have right now that you'd like our help with?

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* 10. Would you like our assistance in accessing Personal Protective Equipment like masks and gloves?

No thanks, I'm good.

Yes, I would like assistance with getting masks

Yes, I would like assistance with getting gloves

Yes, I would like assistance getting masks AND gloves

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* 11. Would you like our support in getting you connected with COVID-19 vaccine clinics?

Yes. I'd like INW to help me find a clinic and get signed up.

No thanks. I have already taken the vaccine.

No thanks. I already have an appointment.

No thanks. I have decided not to take the vaccine.

I prefer not to answer.

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* 12. How would you rate your happiness with your services from Independence Northwest

5 - Very Satisfied

4 - Satisfied

3 - They're Okay

2 - Somewhat Dissatisfied

1 - Very Dissatisfied

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* 13. Do you have any other feedback you'd like to share with us about your experience as an INW customer?

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* 14. If you would like your PA or a member of our team to follow up with you on outstanding questions or concerns, please include your name and best way to contact you (phone or email) and we will be sure to be in touch soon.