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PARTICIPANT SATISFACTION SURVEY
Day Habilitation, Supported Employment, Respite Care, and In-Home Supports
Please let us know how you feel about each statement. For any areas that did not meet your full expectations, please help us understand with specifics in the comment area so we can work to serve you better. All results are kept confidential. Entering your name is optional.
Name of person completing the survey
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First
Last
Participant initials
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Which services are you commenting on?
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Day Habilitation
Supported Employment
Respite Care
In-Home Supports
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Indicates required field
1. My provider is courteous and polite.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
2. My provider treats me respectfully.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
3. My provider understands and cares about me.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
4. My provider listens to what I say.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
5. My provider does a good job of helping me.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
6. My provider usually arrives at the scheduled time.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
7. My provider usually drops me off at the scheduled time.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
8. I am satisfied with the time of day services are provided.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
9. I'm satisfied with the days of the week services are provided.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
10. I feel my provider has the knowledge and skills needed to help me.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
11. I am satisfied with the way my provider and I communicate.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
12. My provider tells me about upcoming changes in my schedule.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
13. I know what goals I am working towards.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
14. I get help with lunch if I need it.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
15. I feel safe with my provider.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
16. My Horizon has made a positive difference in my life by helping me experience the local community things.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
17. My Horizon has made a positive difference in my life because I have made new friends.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
18. My Horizon has made a positive difference to me by helping me adjust to changes.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
19. The staff at My Horizon are happy to help me with my problems.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
20. The staff at My Horizon return calls promptly during business hours.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
21. I am satisfied with the communication between My Horizon and myself.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
22. I think the services I receive help me maintain and improve my quality of life.
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Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Not Applicable
Please add any additional comments here!
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