Client Survey Test » LifeCare Alliance

Client Information:
Name*
First Last
County:*
Age:

Wellness Services (Dietitian Services):
Please answer "YES", "NO", or "UNKNOWN" to the following questions:
Did the Registered Dietitian provide guidance and education that is helping you manage your health condition?*
Did the Registered Dietitian provide education and guidance for your individual needs?*
Comments
Comments
Did the Registered Dietitian give you an opportunity to ask questions?*
Did the Registered Dietitian provide useful resources that you can use or refer to?*
Comments
Comments
Was meeting with the Registered Dietitian worthwhile to you?*
Comments
Would you recommend the Dietitian Services to others?*
Comments
Are the Dietitian Services meeting your needs and/or expectations?*
Comments

Wellness Services (Nursing/Foot Care):
Please answer "YES", "NO", or "UNKNOWN" to the following questions:
The community wellness program assisted me in remaining independent:*
I have a better understanding of what I need to do to stay healthy:*
Comments
Comments
I have maintained or improved functional (mental and physical) abilities:*
The wellness center adds value to my overall health:*
Comments
Comments
I know how to make healthier food choices:*
Comments
Are the Nursing/Foot Care services meeting your needs and/or expectations?*
Would you recommend the Nursing/Foot Care services to others?*
Comments
Comments

IMPACT Safety (Personal Safety):
Please answer "YES", "NO", or "UNKNOWN" to the following questions:
The registration/signup/contracting process was clear, direct and easy to follow:*
The content met my expectations:*
Comments
Comments
I have been able to apply the skills and concepts to my everyday life:*
The program length was appropriate for the class size and content:*
Comments
Comments
Is the IMPACT Safety services meeting your needs and/or expectations?*
Would you recommend the IMPACT Safety services to others?*
Comments
Comments

CHORES (Home Repair):
Please answer "YES", "NO", or "UNKNOWN" to the following questions:
The home repair contractor left the worksite clean and safe?*
The home repair contractor was responsive to my repair needs?*
Comments
Comments
Are the Home Repair services meeting your needs and/or expectations?*
Would you recommend the Home Care services to others?*
Comments
Comments

Meals on Wheels (Home Delivered Meals):
Please answer "YES", "NO", or "UNKNOWN" to the following questions:
The food is attractively served:*
The food is tasty:*
Comments
Comments
I have been able to remain in my own home:*
I have more money for my expenses:*
Comments
Comments
A visit from my driver has positively impacted my outlook on life:*
Comments
Are the Home Delivered Meals services meeting your needs and/or expectations?*
Would you recommend the Home Delivered Meals services to others?*
Comments
Comments
Meals on Wheels (Home Delivered Meals):
Using your own words, please answer the following question:
Please provide any ideas for future menu options:*

Senior Pet Care (Veterinary Services/Food):
Please answer "YES", "NO", or "UNKNOWN" to the following questions:
I would have to sacrifice other important budget items in order to provide for my pet(s) if I didn’t have support from the pet program:*
I feel more confident about meeting my pet’s needs as a result of receiving services through the pet program:*
Comments
Comments
Are the Veterinary Services/Food services meeting your needs and/or expectations?*
Would you recommend the Veterinary Services/Food services to others?*
Comments
Comments
Senior Pet Care (Veterinary Services/Food):
Using your own words, please answer the following 3 questions:
What is the most important part of the pet program?*
How can the pet program be improved?*
Comments
Comments
How has this program most helped you during this past year?*
Comments

Help at Home (Homemaking/Personal Care):
Please answer "AGREE", "DISAGREE", or "SOMETIMES" to the following questions:
My homemaker/personal care aid completes all tasks correctly and completely within the time they're supposed to be here:*
Comments
My homemaker/personal care aid is doing a thorough cleaning job:*
Comments
My homemaker/personal care aid treats me with courtesy and consideration*
Comments
My homemaker/personal care aid is knowledgeable about what I need to be done:*
Comments
The office is effectively communicating to me about service schedules or changes made concerning my service:*
Comments
I would recommend homemaking/personal care services to others:*
Comments

Congregate Dining (Dining Centers/Carrie's Cafe):
Please answer "YES", "NO", or "UNKNOWN" to the following questions:
I am satisfied with the menu options provided by the Dining Center/Carrie's Cafe/Grab and Go Lunches:*
I am satisfied with the taste of the food at the Dining Center/Carrie's Cafe/Grab and Go Lunches:*
Comments
Comments
Participating in a Dining Center/Carrie's Cafe/Grab and Go Lunches has increased my opportunity to socialize with others:*
Participating in the Dining Center/Carrie's Cafe/Grab and Go Lunches has improved by overall access to nutritious food:*
Comments
Comments
Are the Dining Centers/Carrie's Cafe services meeting your needs and/or expectations?*
Would you recommend the Dining Center/Carrie's Cafe services to others?*
Comments
Comments
Congregate Dining (Dining Centers/Carrie's Cafe):
Using your own words, please answer the following question:
Please provide any ideas for future menu options:*

POHC (Project OpenHand Columbus)
Please answer "YES", "NO", "UNKNOWN", or "NOT APPLICABLE" to the following questions:
The pantry boxes and/or frozen meals has improved my overall access to nutritious food during COVID:*
Receiving the pantry boxes and/or frozen meals deliveries helped me provide nutritious food for my family:*
Comments
Comments
Receiving the pantry boxes and/or frozen meals deliveries helped me focus on paying for other bills or non-food related expenses:*
Receiving the pantry boxes and/or frozen meals deliveries helped decrease the number of trips I needed to make to the grocery or pantry during COVID:*
Comments
Comments
Receiving the pantry boxes and/or frozen meals deliveries helped maintain my health:*
Comments
Are the Project OpenHand services meeting your needs and/or expectations?*
Would you recommend the Project OpenHand services to others?*
Comments
Comments

CODA (Camp Hamwi/Youth and Family Programs):
Using your own words, please answer the following 4 questions:
What 3 things are CODA currently doing that are great?*
What are 3 things that CODA could improve?*
Comments
Comments
What other services are you looking for CODA to provide?*
In what ways have CODA’s programs helped your camper’s Diabetes Management improve?*
Comments
Comments
CODA (Camp Hamwi/Youth and Family Programs):
Please answer "YES", "NO", or "UNKNOWN" to the following questions:
Are you satisfied with CODA’s programs?*
Comments
Are the CODA services meeting your needs and/or expectations?*
Would you recommend the CODA services to others?*
Comments
Comments

Farmers Market (Produce Boxes):
Please answer "YES", "NO", or "UNKNOWN" to the following questions:
The Senior Farmers Market Nutrition Program helped me increase the amount of fruits and vegetables I ate this past summer:*
I was satisfied with the variety of produce and honey provided by the Senior Farmers Market Program:*
Comments
Comments
I was satisfied with the quantity of produce and honey provided in the box delivered to me:*
I was satisfied with the quality of produce and honey provided in the box delivered to me:*
Comments
Comments
The produce storage guide provided in the box helped me extend the shelf life of the produce provided to me:*
Comments
Are the Farmers Market services meeting your needs and/or expectations?*
Would you recommend the Farmers Market services to others?*
Comments
Comments

Columbus Cancer Clinic (Mammograms/Cancer Screenings/Food Pantry)
Please answer "YES", "NO", or "UNKNOWN" to the following questions:
Are the Columbus Cancer Clinic services meeting your needs and/or expectations?*
Would you recommend the Columbus Cancer Clinic services to others?*
Comments
Comments

General Agency Questions:
Please answer "AGREE", "DISAGREE", or "SOMETIMES" to the following questions:
How long have you been a client of LifeCare Alliance?*
If client doesn't know, please ask them for a best guess.
- 0-6 Months
- 6-12 Months
- 1-3 Years
- 3-5 Years
- 5-10 Years
- 10+ Years
When I contact Lifecare Alliance, staff are professional and respectful:*
Comments
When I contact Lifecare Alliance, Staff are knowledgeable in handling my request(s):*
Comments
When I contact Lifecare Alliance, staff are responsive to my needs:*
Comments
I'm familiar with all Lifecare Alliance services:*
Comments
I would like someone to contact me about Lifecare Alliance services:*
Comments
Lifecare Alliance services have improved my quality of life and/or independence:*
Comments
Right now, how confident are you that you have the support systems you need to remain at home? (If application ask what are “support systems”, tell them whatever it means to them) Please rate your confidence on a scale of 1 to 5. 1 being NO confidence and 5 being VERY confident*
I would recommend Lifecare alliance to others:*
Comments
Suggestions, improvement(s), and comments:

Client Satisfaction Survey

Client Information:

Services Received:

Wellness Services (Dietitian Services):

Wellness Services (Nursing/Foot Care):

IMPACT Safety (Personal Safety):

CHORES (Home Repair):

Meals on Wheels (Home Delivered Meals):

Meals on Wheels (Home Delivered Meals):

Senior Pet Care (Veterinary Services/Food):

Senior Pet Care (Veterinary Services/Food):

Help at Home (Homemaking/Personal Care):

Congregate Dining (Dining Centers/Carrie's Cafe):

Congregate Dining (Dining Centers/Carrie's Cafe):

POHC (Project OpenHand Columbus)

CODA (Camp Hamwi/Youth and Family Programs):

CODA (Camp Hamwi/Youth and Family Programs):

Farmers Market (Produce Boxes):

Columbus Cancer Clinic (Mammograms/Cancer Screenings/Food Pantry)

General Agency Questions:

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