Survey Placeholder – LifeCare Alliance

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)

15Staff Interaction/Customer Service Quality

16General Agency Questions

Call Script:

Hello, my name is ___________________, and I am calling from LifeCare Alliance. I am wondering if you would be willing to take a few minutes to complete a brief survey with me today so we can measure our customers’ satisfaction, as well as work to continuously improve our program(s). May I have a few moments of your time? I will be asking you questions about your experience with the program, as well as any suggestions you have for us. We promise that the information you provide will be kept strictly confidential. Thank you for your help!

Client Information:

Client ID:*

Name*

First Last

County:*

Age:*

Client Contact Established?*

If client answers, and agrees to participate, please inform them that this call will be recorded for quality and training purposes.

Reason*

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?*

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?*

Was meeting with the Registered Dietitian worthwhile to you?*

Are the Dietitian Services meeting your needs and/or expectations?*

Would you recommend the Dietitian Services to others?*

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:*

I have maintained or improved functional (mental and physical) abilities:*

The wellness center adds value to my overall health:*

I know how to make healthier food choices:*

Are the Nursing/Foot Care services meeting your needs and/or expectations?*

Would you recommend the Nursing/Foot Care services to others?*

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:*

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:*

Is the IMPACT Safety services meeting your needs and/or expectations?*

Would you recommend the IMPACT Safety services to others?*

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?*

Are the Home Repair services meeting your needs and/or expectations?*

Would you recommend the Home Care services to others?*

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:*

I have been able to remain in my own home:*

I have more money for my expenses:*

A visit from my driver has positively impacted my outlook on life:*

Are the Home Delivered Meals services meeting your needs and/or expectations?*

Would you recommend the Home Delivered Meals services to others?*

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:*

Are the Veterinary Services/Food services meeting your needs and/or expectations?*

Would you recommend the Veterinary Services/Food services to others?*

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?*

How has this program most helped you during this past year?*

Help at Home (Homemaking/Personal Care):

Please answer "YES", "NO", or "UNKNOWN" to the following questions:

My Homemaker/Personal Care Aide arrives on time:*

My Homemaker/Personal Care Aide has a professional appearance:*

A visit from my Homemaker and/or Personal Care Aide has positively impacted my life:*

I have more independence in my home because of the help I receive from my Homemaker/Personal Care Aide:*

I look forward to seeing my Homemaker/Personal Care Aide:*

Are the Homemaking/Personal Care services meeting your needs and/or expectations?*

Would you recommend the Homemaking/Personal Care services to others?*

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:*

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:*

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?*

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:*

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:*

Receiving the pantry boxes and/or frozen meals deliveries helped maintain my health:*

Are the Project OpenHand services meeting your needs and/or expectations?*

Would you recommend the Project OpenHand services to others?*

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?*

What other services are you looking for CODA to provide?*

In what ways have CODA’s programs helped your camper’s Diabetes Management improve?*

CODA (Camp Hamwi/Youth and Family Programs):

Please answer "YES", "NO", or "UNKNOWN" to the following questions:

Are you satisfied with CODA’s programs?*

Are the CODA services meeting your needs and/or expectations?*

Would you recommend the CODA services to others?*

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:*

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:*

The produce storage guide provided in the box helped me extend the shelf life of the produce provided to me:*

Are the Farmers Market services meeting your needs and/or expectations?*

Would you recommend the Farmers Market services to others?*

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?*

Staff Interaction / Customer Service Quality:

When interacting and or contacting LifeCare Alliance, were the staff/volunteers:

Professional and Respectful?*

Knowledgeable in handling your request(s)?*

Responsive to your needs?*

General Agency Questions:

How long have you been a client of LifeCare Alliance?*

If client doesn't know, please ask them for a best guess.

Are you familiar with all LifeCare Alliance services?*

Would you like someone to contact you about our services?*

What is the best phone number for someone to reach you?*

Have LifeCare Alliance services improved your quality of life and/or independence?*

Would you recommend LifeCare Alliance to others?*

Do you have any suggestions, improvements, or comments?*

Suggestions, improvement(s), and comments:*

Client Satisfaction Survey

Call Script:

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)

Staff Interaction / Customer Service Quality:

General Agency Questions:

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