Kauai Self-Help Center Survey

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* 1. Survey Date

Date / Time

Date

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* 2. Person saw an attorney?

Yes

If no, why not?

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* 3. Assisted by AmeriCorps Member?

Yes

Comment

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* 4. This is my _______ visit to the Kauai Self-Help Center.

First

Second

Third

Other (please specify)

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* 5. Have you been to the Kauai Self-Help Center since September 1, 2015?

Yes

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* 6. What is the reason for your visit today?

Appeal

Adoption or Guardianship

Harassment or Protection Order

Consumer Debt or Loan

Debt Collection/Garnishment

Personal Injury/Property Damage

Foreclosure

Divorce or Paternity

Child Support

Contract Dispute

Small Claims Case

Garnishment or Execution

Custody Modification

Landlord/Tenant Dispute or Eviction

Other (please specify)

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* 7. Have you or a member of your household served in the U.S. Armed Forces?

Yes

Blank

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* 8. Services provided by volunteer attorney.

Brief Q&A

Extended/In-depth Q&A

Analyzed Documents

Provided Court Forms

Assisted with Forms (prep)

Reviewed completed forms

Assisted with computer research

Assisted with filing

Provided Legal Aid Brochure

Brochure (specify)

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* 9. Check if the visitor was referred to another resource?

Referral

Referred to

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* 10. Limited English language proficiency?

Yes

If Yes, what language?

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* 11. AmeriCorps member services

Q&A

Extended Q&A

Assisted with forms (prep)

Assisted with computer research

Provided court forms

Assisted with filing

Reviewed completed court forms

Analyzed documents

Provided Legal Aid Brochure

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* 12. The following materials would have been helpful.

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* 13. Federal Poverty Level: Family of 1 $1,444 or $17,328 per year.

Under 125%

Between 125%-200%

Between 200%-250%

Above 250%

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* 14. Overall, I am

Very satisfied

Satisfied

Unsatisfied

Very Unsatisfied

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* 15. Satisfaction Survey

	Strongly Agree	Agree	Disagree	Strongly Disagree	Blank
The advice I received today helped me to understand my situation better.	The advice I received today helped me to understand my situation better. Strongly Agree	The advice I received today helped me to understand my situation better. Agree	The advice I received today helped me to understand my situation better. Disagree	The advice I received today helped me to understand my situation better. Strongly Disagree	The advice I received today helped me to understand my situation better. Blank
I know what the next step in the process is.	I know what the next step in the process is. Strongly Agree	I know what the next step in the process is. Agree	I know what the next step in the process is. Disagree	I know what the next step in the process is. Strongly Disagree	I know what the next step in the process is. Blank
The person who assisted me seemed knowledgeable.	The person who assisted me seemed knowledgeable. Strongly Agree	The person who assisted me seemed knowledgeable. Agree	The person who assisted me seemed knowledgeable. Disagree	The person who assisted me seemed knowledgeable. Strongly Disagree	The person who assisted me seemed knowledgeable. Blank
The person listened to what I had to say.	The person listened to what I had to say. Strongly Agree	The person listened to what I had to say. Agree	The person listened to what I had to say. Disagree	The person listened to what I had to say. Strongly Disagree	The person listened to what I had to say. Blank
I did not have to wait long to be served.	I did not have to wait long to be served. Strongly Agree	I did not have to wait long to be served. Agree	I did not have to wait long to be served. Disagree	I did not have to wait long to be served. Strongly Disagree	I did not have to wait long to be served. Blank
I would recommend the Access to Justice Room to a friend with a legal problem.	I would recommend the Access to Justice Room to a friend with a legal problem. Strongly Agree	I would recommend the Access to Justice Room to a friend with a legal problem. Agree	I would recommend the Access to Justice Room to a friend with a legal problem. Disagree	I would recommend the Access to Justice Room to a friend with a legal problem. Strongly Disagree	I would recommend the Access to Justice Room to a friend with a legal problem. Blank

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* 16. How helpful were the services you received?

	Very Helpful	Somewhat Helpful	Not Helpful	Did Not Receive/Blank
Answers to my questions.	Answers to my questions. Very Helpful	Answers to my questions. Somewhat Helpful	Answers to my questions. Not Helpful	Answers to my questions. Did Not Receive/Blank
Assistance with forms.	Assistance with forms. Very Helpful	Assistance with forms. Somewhat Helpful	Assistance with forms. Not Helpful	Assistance with forms. Did Not Receive/Blank
Assistance with filling out forms.	Assistance with filling out forms. Very Helpful	Assistance with filling out forms. Somewhat Helpful	Assistance with filling out forms. Not Helpful	Assistance with filling out forms. Did Not Receive/Blank
Help to prepare for a court hearing.	Help to prepare for a court hearing. Very Helpful	Help to prepare for a court hearing. Somewhat Helpful	Help to prepare for a court hearing. Not Helpful	Help to prepare for a court hearing. Did Not Receive/Blank
Help to follow up with court orders.	Help to follow up with court orders. Very Helpful	Help to follow up with court orders. Somewhat Helpful	Help to follow up with court orders. Not Helpful	Help to follow up with court orders. Did Not Receive/Blank
Educational materials.	Educational materials. Very Helpful	Educational materials. Somewhat Helpful	Educational materials. Not Helpful	Educational materials. Did Not Receive/Blank
Information on where to get more help.	Information on where to get more help. Very Helpful	Information on where to get more help. Somewhat Helpful	Information on where to get more help. Not Helpful	Information on where to get more help. Did Not Receive/Blank
Help using computer to obtain information or prepare documents.	Help using computer to obtain information or prepare documents. Very Helpful	Help using computer to obtain information or prepare documents. Somewhat Helpful	Help using computer to obtain information or prepare documents. Not Helpful	Help using computer to obtain information or prepare documents. Did Not Receive/Blank
Other (please describe)	Other (please describe) Very Helpful	Other (please describe) Somewhat Helpful	Other (please describe) Not Helpful	Other (please describe) Did Not Receive/Blank

Other (please describe)

Kauai Self-Help Center Survey

Question Title

* 1. Survey Date

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* 2. Person saw an attorney?

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* 3. Assisted by AmeriCorps Member?

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* 4. This is my _______ visit to the Kauai Self-Help Center.

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* 5. Have you been to the Kauai Self-Help Center since September 1, 2015?

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* 6. What is the reason for your visit today?

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* 7. Have you or a member of your household served in the U.S. Armed Forces?

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* 8. Services provided by volunteer attorney.

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* 9. Check if the visitor was referred to another resource?

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* 10. Limited English language proficiency?

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* 11. AmeriCorps member services

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* 12. The following materials would have been helpful.

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* 13. Federal Poverty Level: Family of 1 $1,444 or $17,328 per year.

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* 14. Overall, I am

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* 15. Satisfaction Survey

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* 16. How helpful were the services you received?

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* 17. How else could we have helped you today?

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* 18. Please share any other comments or suggestions you have about the Kauai Self-Help Center?

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* 19. AmeriCorps members: Please use this space to enter your comments or any other relevant information for this month.