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Information and Assistance Satisfaction Survey

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* 1. First, did you contact (NAME OF PROVIDER) to obtain help or services for yourself, for a relative or someone you know, or were you inquiring from an agency for a client or a patient? (CHECK ALL THAT APPLY)

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* 2. Please tell me the reason why you contacted (NAME OF PROVIDER). (CHECK ALL THAT APPLY)

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* 3. Had you ever used this service before last week?

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* 4. If you called (name of provider) last week, did you get a busy signal?

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* 5. How quickly was your call answered?

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* 6. Was the initial phone call answered by voice mail or by a person?

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* 7. Overall, did the person listen carefully to what you wanted?

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* 8. Overall, did the person understand what you wanted?

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* 9. Did she/he explain things in a way that you could understand?

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* 10. Did you experience any of the following communication problems? (Check all that apply)

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* 11. Overall, did you receive the information from (NAME OF PROVIDER) that you were looking for?

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* 12. Overall, how satisfied were you with the way your inquiry was handled?

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* 13. Would you recommend this service to a friend or colleague who needs the kind of information and assistance you did?

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* 14. Do you expect that the information you received from (NAME OF PROVIDER) will be helpful in resolving the issue you inquired about?

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* 15. Were you referred to any other places for a service or more information?

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* 16. If you were referred to another office or agency, did you contact any other places besides that referral to get the information you needed?

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* 17. Do you have any recommendations on how to make (NAME OF PROVIDER) better? (CHECK ALL THAT APPLY)

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