HomeMy WebLinkAboutAttachment E�iI.—.?\-TI—D,? DE C� )T : TY 1-Ic= %FE � SS T :T
PROGRAM RATE G OF S.AT7.SF_ACTI0
INSTR t CTl0\
C srefuliv read all of the instructions below BEFORE distributing the Program Ratin,o of Satisfuc1,
sLln'el' to 1 our Pronrarn participants.
General Information
The Proryram Rating of Satisfaction consists of l I items which are used to determine a eiict;t s sati_factic r
.With ser -ices they are recei ving from a prOv�lder. It is to be completed b' all progran-, I)LIIIicihants er-L-Itd
in sen ices at a Trust -funded program. It mus: be completed - at a minimum - at ,Jule of'dischar_'e for all
participants. Itis strong]' recommended that a Program Rating of Satisfaction sunvev also be completed at
irrten'als as may be applicable to the program; however. only the discharce survey must be fornarded to the
Homeless Trust. Case management notes should indicate specifically why a Program Rating of Satisfaction
was not obtained, if that is the case (client went Alr'OL, institutionalized. etc.), and what efforts «ere made
to obtain a survey in those instances.
The Program Rating of Satisfaction is available in English, Spanish and Crecle. Providers are responsible
for reproducing the appropriate survey a_nd providing an envelope (that seals) for each respondent. -Ail,
responses should be completed in ilik
If a participant cannot read, providers should encourage Them to use the same process they use to have
ogler information read to them. An employee o7tlie agency that is not directly responsible for the client's
care can read the form. This should be indicated in Section II. as a separate set of staff initials.
Fillin_ out the form
I) o language appropri
to ate survey and an envelope should be provided to all participants who are required
complete the form. Only one form per family is required. The form must be filled out in ink.
?) Section hI of the Program Rating of Satisfaction is to be completed by staff prior to providing the
survey document to the program participant. Staff initials refers to the initials of the case mana� er
responsible for the client's service delivery. If the survey must be read to the client, the initials of the
Staff Person perfbi-Ming that funeticn should also be included. In no case should the participant's case
manager read items aloud to the participant.
�
) Section I of the Program Rating of Satisfaction Form is to be filled out ONLY by the program
participant. The program participant should be provided a private place and sufficient time to answer
the surrey.
=1) Providers should reassure participants of the confidentiality of their responses. Providers nlav wish to
introduce the survey, as follo«js:
"This sun'ey is one 4vay of helping us determine how wt1l %ve are liclpin iridividuals that
come to our agency for assistance. Please iai:e a fe\,. minutes a cr i Icavt to answEr this ver -V
short sunlev as honestly as possible. Your respons s are priVat-_ and V,'e \VII1 not look at them
Please seal the envelope and give it to me % hen you are done (or: Put it in the drop boxj"
The completed sunev should be placed in the enveloT"z- b lite rvcipi •ntand sealed. I'ro,iders are
encouraged to provide 3 "drop box_..'.ith a slot for coropler'— forms.
01 TI -1i sealed enve:Io e(s) shoLi! d be fCn',ardId iC I h t 1\'lianI (_oUni,,f OiZie1f_- 1 rust on 3 [nontlii�:
bases. `
The pros ider 3Ren'c i' shou'id mal i t«ln a to of ho\ — 'v sur'._ d;a:.;butcJ.
DETEIt111NATION OF MINT -NIDI AVER-AG1- �-CORT FOJ\I
CONSUATER $ATISFACT10� St'R\.'E1
I 1 was informed of ms rights and responsibilities
1 was provided with information about different sen -ices
that are avoilable for me
1 was involved in making decisions about my care!scn ice
!an
I I+as able to talA with staff when I needed to
The building and facilities ha�•e usually been clean, safe and
comfortable
It'iy rights were respected and protected, including m~ , right
to file a arievancc, if needed
My case manager seems qualified to help m e
1 would recommend this program to others
I am treated with respect by the staff
The staff seems to care about whether I get better
Program staff trere.knowledgeable about available services
that could help me
11/6/00
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RECOMMENDED
57.17
57.00
NI ANII-D-ADF COL�"�TY HCI.�.IELESS TRUST
PR0GRA+ 1 RATI,'N'G OF SATISFACTI0N
Section I.. -TO BE COMPLETED BY PROGi.A.kl PARTICIPANT
Irrstrucrions: Please ajrswcr each queslim helow h)' plasm, an /af ii, rhe spnCe PrOrided. YOur rC cPerr.tes ra these
yrfcstions hate rro hearrrzO nn i'0ur crirlifrued porricination in llre nrn«rrnzr. A_' L responses me can(Identiul.
Wh)' did )ou choose to enter- the program (mark onk one box):
01 decided to come to this program on my o%,, -n (throLi2h outreach. referral. etc. i
OI was placed here tlrnufih another program (court in«rTent;on, police. etc.; a2a1nsl m\ +ill
1:11 had previous])participated in this or a similar program and decided to return
OPTIONAL Information:
Name:
Today's Date:
Scx: ❑ male ❑ female
Please arzsmer the Jl)HDwing gzresrioizs about the services }'ou rereinled Mari ;V/ f orrlV One hox which hese
describes your feelings ahoi,1 euCh statement. These questions arc rnerrnr to help us iniprnve the services provided,
SO we ask that yore tell us how roti rcclly feel, whether or rrol i1 is 000d or had.
sfronglr Agree-9greeCr ( Disagree Disa;ree I Srrnr�olr
4 re c I Lirrle -1 Lirf'c + Dicn rec
1 -2s informed of my rights and; [4] (31 (?] l)
including the agency's c7rieN21,ce procedures
I was provided with information about d irferent ser�.ices
21I,
t are at'ailable for me
I was involved in making decisions about my
care/sen'ice plan
1 vvas able to fall{ with staff when 1 needed to
The building and facilities have usually been clean, safe
and comfortable
My riclhts were respected and protected, including my
richt to file a Prievance, if needed
AIN, case manager seems qualified to help me
I would recommend this prozram to others
I am treated Frith respect by the staff
The staffseems to care about whether I tet better
Program staff Were knowledgeable about nvoilable
services that could help me
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,lection IT.: TO -13E COMPLETED BY PROGP-4-M STAFF
( PrrrPose Qf El"Clualion
G AI Admission
Q At discharpe
+ Other:
i
(
[•."• Z i•�C�i (��J rtNftS�7rQe„7 r, it�t u.
j Currew Level of Carc provided
I❑ emeral-Pc �e hcus nn
D transitional housine!ts
1 Ci transitional housinE'f'non-t,%,
i
C pe.-manent housing
services only'
f'rnvidcr iNurne:
I Project 'role:
IStaff lfwi,ils: _
i
t
Ml -A :TI-D_ADE COU,`TY HOMELESS TRUST
EVAL.L1.ACI6\' DE L-A SATISTACCiON CON EL PROGRA�J.A
Seccion 1. CONTPLETADA POR EL PaRTIrIPA"�'TE DEL PRQGF� 4,' I -A
lrrsrruccior7es: Por furor coloque lino cr7r /._1% en el rspocio prof istu porn r'sp+lrrdCr u It!s pre{'uIilu� n Coll [ill iu'n L rn
respuesros quo usred de e esre cuesfionori0 171) ir7/luirdr7 de 1'nr»7a alrunn snhrc lu cnnrinuncinrn do su pur7icinucinn 4177 c'%W
ro eromc. TODAS las respuos/as Sr rranre/7dr6rr r077fidrr7rialn7cr7re.
Por que decidi6 listed partieipar en el programa.' (Marque una casilla solamemc):
[ J Lo decidi por mi cuenia (porque fui r=_mitido o por medic, de otTO proerama, etc )
[ ] Fui colocado aqui mediante otro programa (por inte,vEnci6n de los mbuna)rs. la
Policia, etc.) en contra de mi voIuntad
[ ) Ya habia pamcipado en este programa o en Lino similar v decidi re2resar
Inform2cj6n OPCIONAL:
Nombre y ope)lido:
I•:echa de bey:
Genero: M [ J F[ ]
Por favor re5p0,7d12 a 1asArea urfas sicluienres acerca de los serricios g7Je se le ham preslado. Indigue con una crnr [ j LN
Lr11.4 SOLA C.4SILL.4 POR PRE-GUh'T.4 Ia forma en que ustrd se .creme arerca de nada lino de ias cursriones descrilrts.
C01770 sus respuesfas a esras prep untas nos at'udardr7 a mejorar los servicios que presramos, le rn; annrs que nus Ira; n saber
tomo se sienre en reQlidad acerca de nueslr oS scrvici05, 770 i177pornr Si usred los c017sidero buenns u 177810S.
,Seccion II.: COMPLETADA POR EMPLEADO-S DEL PROGRA;,VIA (completed bv program staff)
Purpose of E;,aluorion
Ala} de
De
Al -e de
Al, -o en
I En
Niuv rn
-1 AT discharaa
acuerdo
acuerdo
acuerdo
dc4acucrdo I
desacucrdn
I dcsacucrdo
Se me informaron Ctldles ei-an mis derechos}i
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responsabilidades, entre elios, los procedimientes de la
scr vices oniv
aoenCiaara someter queias.
i
Se me dio informaci6n sobre los distintos servicios a los
I [6]
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lie tenQo derecho.
Participe en la toma de decisiones referentes a mi pin n[6)
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de 2tenci6rny servicios.
Pude habiarcon el personal cuando tine necesidad de
[6)
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hacerin.
E1 centro e sus servicios por to general se han mantenido +
[6]
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Jim ios, sin e"Oro y 2ccesibles.
Se respetaron y protegieron mis derechos, entre ellos, mi
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derecho a someter uejas si to considero necesario.
Aparentemente, la persona encargada de mi caso Babe to +
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U tiene . lie hacer ara :3vudarme.
Yo les recomendaria este ro)'ecto a otras ersonas. j
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Los em leados me trataron res etuosamente. (
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Aparentemente, a los empleados les interesa queyo I
[6]
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me -ore.
Los empleados sobian queservicios pbdi3n servirme de I
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ati'uda. I
,Seccion II.: COMPLETADA POR EMPLEADO-S DEL PROGRA;,VIA (completed bv program staff)
Purpose of E;,aluorion
I C'urrenr Levcl of Curd providei/
I
D At Admission
I 0
emergence housing
Provider Name:
-1 AT discharaa
i `I
transitional housineir::
� Project Warne:
_O
Lither:
j
transitional housn�'non-t'.:
tali Iniciuls:
f
pernianenl housing
D
scr vices oniv
MI TI -DADS TR1_'ST
PN�VOGRAM POS.) EV LYE SATISFAKS)-ON
Section I. TOUT P.ATISI)).AN \'.k;\ F�OGRA)I SILA A FFT PC) U R_.0'PLJ J'AJ SA A
EnslriAs)°arr: Tanpri repor;n chak keksiion anba la a epi f l on ti k wo /.v% 11(212 c'sp"75 ki I irl lei. Rcn„n; „nu hnt r o
Pon dcranje %aSnn nap honrinve parlsipe non 171c'OfTOn7 cilli a T0ul,rep0n5.0 ap sel r .
POM 11' CHWAZI PATISIPL SILA A (fe.von ti k%Na nan ion
Brenn bvrat):
JJ Se mtiren ki chu'azi vinn lion pwogram silo a (sera pa referons, s`ia pa S6'is espcs}al :Isistans piblik tic.)
ij Se Pa chwo mwen, se yon lot pvoeram ki vovem jzak tribinal, lapolis etc)
jJ Mien to dejn patisipe nan yon pwocrarn konsa epi mwon Beside retounnen.
Enfomasyon lou bal' si W vIe:
Non:
Dat Jod},a:
Sel's 1] Cason () Fenrn
- Tanpri reponn keksyorr Bila yo dapre sevis w resciwa. Fe yar7 kwalxjnan von sel t'i kare epi cinva-i repons ki plis
matclre ave w. Xeksyon silo vo to you ede noct bav pi bor7 sePis, alb noar nzar7de noir bnl rcpnr7s ki plis matclle live
H', ke H bon o)r pa. -
Yo f&m konnen tout drva mwen yo ak responsabiliie
mwen yo ak kouman you mwen plenven nan ajans ]a
"o to banmwen enfomasyon sou diferan sevis ke mwen
kab jwenn
Esekirife
isipe nan tout desizyon sou planifikasyon
wen
te toujou Bis onib ou MWen pale 2vek vo
ingyo to toujou byen pwop, konfotab ak
Tout dtira m to respekte ak pw6teje rnenrn diva m you
moven to ote lent si neses&
, kap okipeIca rnwen an sanble li kalifye you li
Idem
Mwen t3 rekomande pwo2ram sila a boy lot moun
Amphvaye vo trete moven ak resp&
Amplw2yc yo sanble vo vrernan enterese nan rnwen
Ampl'sayepwogram la to byen en5mesou touts&vis ki
to disponib you edc m.
Bon jan
da k6
J dako
I J
I Dnkb
tou piti
Pa flnn
r)%,b c
Pa dal;o
i Pa dako
J d,tou
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Section II.: TO BE CO?IIPLETFD BY PROGP 46, I STAFF
19rrpnse ofEva/uarion
Current Level of Cure providCd
i
At Admission
I
D emehousin,
Provider Name:
1 _
! .fit dischflr2`
-
I ❑-anSltlOnai iIOL'Sinc'C?:
i f'rO+Cct iMnlc:
[i (lilt r
-
J C transitional housjn2inon-r,;
—
; Staff Initials:
'
Ci nf,'7,-,2neni hcusln2
t':�•l.t 1/G��17 YDfI?};111; C°r�f�f Jllnp