Family Satisfaction Survey

Thank you for working with RSVP, Inc. Your satisfaction with our services is of the utmost importance. We welcome your feedback and suggestions.

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* 1. Please enter the Consumer's Name

Consumer's Name

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* 2. Please enter your name and your relationship to the consumer

My Name

Relationship to Consumer

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* 3. Please enter the RSVP, Inc. Specialist's Name

RSVP, Inc. Specialist's Name

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* 4. Please select the current service status:

Initial

Ongoing

Follow-Along

Case Closure

Please select the most appropriate response to the following statements.

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* 5. The consumer had input when making a job choice.

False

Somewhat False

Uncertain

Somewhat True

True

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* 6. The consumer was helped to get ready to work in the community.

False

Somewhat False

Uncertain

Somewhat True

True

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* 7. The consumer has learned new job skills.

False

Somewhat False

Uncertain

Somewhat True

True

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* 8. The consumer's job goal fits his/her interests.

False

Somewhat False

Uncertain

Somewhat True

True

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* 9. The consumer has reliable transportation.

False

Somewhat False

Uncertain

Somewhat True

True

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* 10. Family members are treated with respect by RSVP, Inc. staff.

False

Somewhat False

Uncertain

Somewhat True

True

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* 11. The consumer is safe in the community.

False

Somewhat False

Uncertain

Somewhat True

True

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* 12. The consumer has identified a salary goal.

False

Somewhat False

Uncertain

Somewhat True

True

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* 13. The consumer enjoys the job preparation/development process.

False

Somewhat False

Uncertain

Somewhat True

True

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* 14. Family members like working with RSVP, Inc. staff.

False

Somewhat False

Uncertain

Somewhat True

True

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* 15. The consumer receives SSI/SSDI disability benefits?

Yes

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* 16. The consumer is able to maintain SSI/SSDI disability benefits?

Yes

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* 17. The consumer is able to maintain Medicaid (SSI), Medicare (SSDI), or other health benefits?

Yes

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* 18. The consumer receives Medicaid (SSI), Medicare (SSDI), or other health benefits?

Yes

Family Satisfaction Survey

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* 1. Please enter the Consumer's Name

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* 2. Please enter your name and your relationship to the consumer

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* 3. Please enter the RSVP, Inc. Specialist's Name

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* 4. Please select the current service status:

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* 5. The consumer had input when making a job choice.

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* 6. The consumer was helped to get ready to work in the community.

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* 7. The consumer has learned new job skills.

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* 8. The consumer's job goal fits his/her interests.

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* 9. The consumer has reliable transportation.

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* 10. Family members are treated with respect by RSVP, Inc. staff.

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* 11. The consumer is safe in the community.

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* 12. The consumer has identified a salary goal.

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* 13. The consumer enjoys the job preparation/development process.

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* 14. Family members like working with RSVP, Inc. staff.

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* 15. The consumer receives SSI/SSDI disability benefits?

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* 16. The consumer is able to maintain SSI/SSDI disability benefits?

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* 17. The consumer is able to maintain Medicaid (SSI), Medicare (SSDI), or other health benefits?

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* 18. The consumer receives Medicaid (SSI), Medicare (SSDI), or other health benefits?

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* 19. The consumer has out-of-pocket disability-related work experiences (i.e., transportation, medications, supplies, etc.)?

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* 20. Things I like about the services/outcome:

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* 21. Things I do not like about the services/outcome:

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* 22. Date Survey Completed