Consumer Experience Survey - County of Los Angeles Aging & Disability Resource Connection

1.Which agency or organization provided your services?(Required.)

I am a recipient of services

I am a caregiver of recipient of services

I am a caregiver receiving services

None of the above

2.Which agency or organization provided your services?(Required.)

Communities Actively Living Independent and Free (CALIF)

Disabled Resources Center (DRC)

Disability Community Resource Center (DCRC)

City of Los Angeles Department of Aging/Area Agency on Aging

Independent Living Center of Southern California (ILCSC)

Service Center for Independent Life (SCIL)

California Resource Services for Independent Living (CRS-IL)

Please rate the following items according to your level of agreement: agree, neither agree nor disagree, disagree, or not applicable.

3.My interests and needs were discussed(Required.)

Disagree

1 smiley

Neither Agree or Disagree

2 smileys

Agree

3 smileys

N/A

4.I was treated with courtesy and dignity(Required.)

Disagree

1 smiley

Neither Agree or Disagree

2 smileys

Agree

3 smileys

N/A

5.I have more information and choices because of the services/assistance I received(Required.)

Disagree

1 smiley

Neither Agree or Disagree

2 smileys

Agree

3 smileys

N/A

6.I am more confident that I will be able to manage my life better because of the services/assistance I received(Required.)

Disagree

1 smiley

Neither Agree or Disagree

2 smileys

Agree

3 smileys

N/A

7.The services/assistance I received improved my health, safety, and/or well-being.(Required.)

Disagree

1 smiley

Neither Agree or Disagree

2 smileys

Agree

3 smileys

N/A

8.What, if anything, could we have done better?

9.What kind of help or services were you looking for?

10.Based on your experience, what did you find helpful?

I received information and referrals for services.

I said what my goals were and I was given choices to help meet my needs.

I received help for an urgent need.

I received help going back to my home after being in a hospital or other place that cared for me.

I did not find the program helpful

Other (please specify)

11.Please rate your overall experience

Satisified

1 smiley

Neither Satisfied nor Dissatisified

2 smileys

Dissatisfied

3 smileys

12.May we contact you to discuss your experience?

Yes

13.If you want us to follow up with you, please provide your information.

Name

Email Address

Phone Number