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Client Satisfaction Survey

Revision 1 - 11/16/2021

"*" indicates required fields

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:

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

Services Received:

Please choose the appropriate response from the following options:
What services are you receiving from LifeCare Alliance?

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 "YES", "NO", or "UNKNOWN" 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:

Staff Interaction / Customer Service Quality:

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

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.
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