Northern Health Residential In Reach Program Client Experience Survey

Providing people with an effective, efficient and friendly community service is important to us. This survey provides you with an opportunity to make any comments that will help us improve our community based programs. The survey is anonymous but we are happy to discuss any concerns you’d like to raise.

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* 1. Person completing this survey:

Resident

Family/friend

Facility staff member

Other (please specify)

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* 2. Facility Name (Optional)

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* 3. Please tell us what area/region you are from:

Northern Health local area

Goulburn Valley Health Residential In Reach area

Kilmore

Hume region (none of the above)

Other (please specify)

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* 4. Please rate the following statements about Northern Health Residential In Reach:

	Never	Rarely	Some of the time	Most of the time	Always
Northern Health staff treat me with respect and dignity	Northern Health staff treat me with respect and dignity Never	Northern Health staff treat me with respect and dignity Rarely	Northern Health staff treat me with respect and dignity Some of the time	Northern Health staff treat me with respect and dignity Most of the time	Northern Health staff treat me with respect and dignity Always
I have confidence and trust in the Northern Health staff who are caring for me	I have confidence and trust in the Northern Health staff who are caring for me Never	I have confidence and trust in the Northern Health staff who are caring for me Rarely	I have confidence and trust in the Northern Health staff who are caring for me Some of the time	I have confidence and trust in the Northern Health staff who are caring for me Most of the time	I have confidence and trust in the Northern Health staff who are caring for me Always
Northern Health staff follow up and report back when I raise issues with them	Northern Health staff follow up and report back when I raise issues with them Never	Northern Health staff follow up and report back when I raise issues with them Rarely	Northern Health staff follow up and report back when I raise issues with them Some of the time	Northern Health staff follow up and report back when I raise issues with them Most of the time	Northern Health staff follow up and report back when I raise issues with them Always
I understand the information I am given by the Northern Health staff	I understand the information I am given by the Northern Health staff Never	I understand the information I am given by the Northern Health staff Rarely	I understand the information I am given by the Northern Health staff Some of the time	I understand the information I am given by the Northern Health staff Most of the time	I understand the information I am given by the Northern Health staff Always
I participate in making decisions about the care and services received from the Northern Health Residential In Reach Program	I participate in making decisions about the care and services received from the Northern Health Residential In Reach Program Never	I participate in making decisions about the care and services received from the Northern Health Residential In Reach Program Rarely	I participate in making decisions about the care and services received from the Northern Health Residential In Reach Program Some of the time	I participate in making decisions about the care and services received from the Northern Health Residential In Reach Program Most of the time	I participate in making decisions about the care and services received from the Northern Health Residential In Reach Program Always
I get the services I need from the Northern Health Residential In Reach Program	I get the services I need from the Northern Health Residential In Reach Program Never	I get the services I need from the Northern Health Residential In Reach Program Rarely	I get the services I need from the Northern Health Residential In Reach Program Some of the time	I get the services I need from the Northern Health Residential In Reach Program Most of the time	I get the services I need from the Northern Health Residential In Reach Program Always

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* 5. Overall, how would you rate the care provided by Northern Health Residential In Reach Program?

Very poor

Poor

Adequate

Good

Very good

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* 6. Happy with your care or the service you received from Northern Health Residential In Reach Program? Tell us what we did well:

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* 7. Unhappy with the service you received from Northern Health Residential In Reach Program? Tell us about your concerns:

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* 8. What would have made a difference?

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* 9. Would you like to be contacted by a manager to discuss your feedback? This will not affect the care that you receive.

Yes