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2010 Special Neighbors Program Participant 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 participant:

Name of person/s completing survey:

Created with SurveyGold survey tools - www.surveygold.com


Satisfaction Survey Questions

Do you feel safe and comfortable in your home?
Yes
No
I don't know

Do you feel your staff treat you the way you want to be treated?
Yes
No
I don't know

Do you feel your staff responds in a timely manner when you ask for assistance?
Yes
No
I don't know

Do you feel your staff help you to spend time with family and friends most of the time?
Yes
No
I don't know

If/When you request help do you feel staff assist you to spend time with family and friends?
Yes
No
I don't know

Do you feel you have food at meals that you like?
Yes
No
I don't know

Do you feel you participate in activities that you enjoy?
Yes
No
I don't know

Are you happy with choices regarding your routine (meals, snacks, activities, going to bed, etc.)?
Yes
No
I don't know

Do you feel safe when being transported in the van or car by Special Neighbors staff?
Yes
No
I don't know

Do you know how to get your personal money (personal needs, payroll, etc.)?
Yes
No
I don't know

Do you feel your health care problems get treated in a timely manner?
Yes
No
I don't know

Additional Comments:

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