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Caregiver Programs Customer Satisfaction Survey, F-02331 (05/2018)

Please rate how well Wisconsin family caregiver programs met your needs. Your confidential responses will be used to improve the quality of our services.

1. What county or tribe provided services?

2. What is today's date? This question requires a valid date format of MM/DD/YYYY.

calendar

3. How did you first make contact with the caregiver program about your concerns?

Please enter an 'other' value for this selection.

4. How much time passed between your request for help and your first meeting or discussion with a staff person about your request

5. How would you rate the amount of time that passed until you discussed your situation with the staff person?

6. Rate the following aspects of your interaction with the person who spoke to you:

Space Cell	Very Well	Well	No Opinion	Poorly	Very Poorly
How well or poorly did program staff listen to you?	How well or poorly did program staff listen to you?: Very Well	How well or poorly did program staff listen to you?: Well	How well or poorly did program staff listen to you?: No Opinion	How well or poorly did program staff listen to you?: Poorly	How well or poorly did program staff listen to you?: Very Poorly
How well or poorly did the staff person understand your situation?	How well or poorly did the staff person understand your situation?: Very Well	How well or poorly did the staff person understand your situation?: Well	How well or poorly did the staff person understand your situation?: No Opinion	How well or poorly did the staff person understand your situation?: Poorly	How well or poorly did the staff person understand your situation?: Very Poorly
How well or poorly was your privacy respected?	How well or poorly was your privacy respected?: Very Well	How well or poorly was your privacy respected?: Well	How well or poorly was your privacy respected?: No Opinion	How well or poorly was your privacy respected?: Poorly	How well or poorly was your privacy respected?: Very Poorly
How well or poorly did the information you received meet your needs?	How well or poorly did the information you received meet your needs?: Very Well	How well or poorly did the information you received meet your needs?: Well	How well or poorly did the information you received meet your needs?: No Opinion	How well or poorly did the information you received meet your needs?: Poorly	How well or poorly did the information you received meet your needs?: Very Poorly

7. Would you recommend that a friend or family member with similar needs contact the county aging unit/aging and disability resource center/tribe?

8. Is there anything else you would like to tell us about your experience?