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Client Satisfaction Survey

1Client Information
2Services Received
3Wellness Services (Dietician Services)
4Wellness Services (Nursing/Foot Care)
5IMPACT Safety (Personal Safety)
6CHORES (Home Repair)
7Meals on Wheels (Home Delivered Meals)
8Senior Pet Care (Veterinary Services/Food)
9Help at Home (Homemaking/Personal Care)
10Congregate Dining (Dining Centers)
11POHC (Project OpenHand Columbus)
12CODA (Camp Hamwi/Youth and Family Programs)
13Farmers Market
14Columbus Cancer Clinic (Mammograms/Cancer Screenings/Food Pantry)
15General Agency Questions
  • Client Information:

  • Services Received:

    Please choose the appropriate response from the following options:
  • Wellness Services (Dietitian Services):

    Please answer "YES", "NO", or "UNKNOWN" to the following questions:
  • Wellness Services (Nursing/Foot Care):

    Please answer "YES", "NO", or "UNKNOWN" to the following questions:
  • IMPACT Safety (Personal Safety):

    Please answer "YES", "NO", or "UNKNOWN" to the following questions:
  • CHORES (Home Repair):

    Please answer "YES", "NO", or "UNKNOWN" to the following questions:
  • Meals on Wheels (Home Delivered Meals):

    Please answer "YES", "NO", or "UNKNOWN" to the following questions:
  • Meals on Wheels (Home Delivered Meals):

    Using your own words, please answer the following question:
  • Senior Pet Care (Veterinary Services/Food):

    Please answer "YES", "NO", or "UNKNOWN" to the following questions:
  • Senior Pet Care (Veterinary Services/Food):

    Using your own words, please answer the following 3 questions:
  • Help at Home (Homemaking/Personal Care):

    Please answer "AGREE", "DISAGREE", or "SOMETIMES" to the following questions:
  • Congregate Dining (Dining Centers/Carrie's Cafe):

    Please answer "YES", "NO", or "UNKNOWN" to the following questions:
  • Congregate Dining (Dining Centers/Carrie's Cafe):

    Using your own words, please answer the following question:
  • POHC (Project OpenHand Columbus)

    Please answer "YES", "NO", "UNKNOWN", or "NOT APPLICABLE" to the following questions:
  • CODA (Camp Hamwi/Youth and Family Programs):

    Using your own words, please answer the following 4 questions:
  • CODA (Camp Hamwi/Youth and Family Programs):

    Please answer "YES", "NO", or "UNKNOWN" to the following questions:
  • Farmers Market (Produce Boxes):

    Please answer "YES", "NO", or "UNKNOWN" to the following questions:
  • Columbus Cancer Clinic (Mammograms/Cancer Screenings/Food Pantry)

    Please answer "YES", "NO", or "UNKNOWN" to the following questions:
  • General Agency Questions:

    Please answer "AGREE", "DISAGREE", or "SOMETIMES" to the following questions:
  • If client doesn't know, please ask them for a best guess.
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