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2010 Special Neighbors Family Satisfaction Survey
Answer questions as they relate to you. For most answers, check the boxes most applicable to you or fill in the blanks.
Demographic Information
Name of Person Completing Survey:

Relationship to Participant:
Family Member
Friend
Service Coordinator
Public Administrator

E-mail Address (Optional):

Are you interested in receiving Special Neighbors information through your e-mail address?
Yes
No

My family member receives support through the following program:
Carriage House
Manor House
Main Street House
Nolen Manor
White Oaks
Special Neighbors Apartments
Individualized Supported Living
Community Integration (10 to 45 hours of supports provided per month)

Created with SurveyGold online surveys - www.surveygold.com

Satisfaction Survey Questions
Are you happy with your family member's current living arrangement?
All of the time
Most of the time
Some of the time
Rarely
Undecided/Don't Know

Is your family member's home safe and comfortable?
All of the time
Most of the time
Some of the time
Rarely
Undecided/Don't Know

List any comments or concerns regarding his/her living arrangement and comfort and safety of his/her home.

Are you satisfied with the variety of healthy food available where your family member lives?
All of the time
Most of the time
Undecided/Don't Know
Some of the time
Rarely

List any comments or concerns regarding the variety of healthy food available.

Are you satisfied with the amount of interactions/supports provided by staff that your family member receives?
All of the time
Most of the time
Some of the time
Rarely
Undecided/Don't Know

If/when needed are you satisfied with support (including transportation) provided by staff to help your family member participate in leisure activities?
All of the time
Most of the time
Some of the time
Rarely
Undecided/Don't Know

List any comments or concerns regarding the amount of interactions/supports or support to help your family member to participate in leisure activities.

Is your family member safe with the transportation offered by Special Neighbors?
All of the time
Most of the time
Some of the time
Rarely
Undecided/Don't Know

Are you satisfied with the choices offered by staff to your family member regarding his/her everyday routine (meals, snacks, activities, going to bed, etc.)?
All of the time
Most of the time
Some of the time
Rarely
Undecided/Don't Know

Are you satisfied with the amount of contact you have with your family member?
All of the time
Most of the time
Some of the time
Rarely
Undecided/Don't Know

List any comments or concerns regarding safety of transportation or choices offered by staff to your family member.

When you express concerns, are you concerns addressed in an efficient and professional manner?
All of the time
Most of the time
Some of the time
Rarely
Undecided/Don't Know

Are you satisfied with the health care monitoring he/she receives?
All of the time
Most of the time
Some of the time
Rarely
Undecided/Don't Know

List any comments or concerns regarding concerns addressed efficiently and professionally and health care of your family member.

All staff are trained in CPR, First Aid, Medication Administration, Bloodborne Pathogens, HIPAA, and Abuse and Neglect. Is their any other specific training that you feel Special Neighbors should provide to staff?
(Provide up to three responses.)

Do you receive notice of your family member's yearly planning meeting?
Yes
No

How can Special Neighbors improve?

Are there any additional services you would like to see Special Neighbors offer?

Additional Comments/Concerns/Compliments:

Created with SurveyGold online surveys - www.surveygold.com