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MIAN,fI-DADE COL'THOMELESS T UST
PROGRAM RATING OF SATISFACTION
INSTRt CT10\S
Carefully read all of the instructions below BEFORE distributing, the Program Rating of Satisfaction
survey to your program participants.
General Information
The Program Rating. of Satisfaction consists of .1 I items which are used to determine a Client s satisfaction
with services they are receiving from a provider. It is to be completed by all program participants enga<g.ed
in services at a Trust -funded program. It must be completed - at a minimum - at time of discharge for all
participants. It is strongly recommended that a Program Rating of Satisfaction survey also be completed at
intervals as may be applicable to the program; however, only the discharge survey must be forwarded to the
Homeless Trust. Case mananernent notes should indicate specifically why a Program RatinC7 of Satisfaction
was not obtained, if that is' the case (client went AWOL, institutionalized, etc.), and what efforts were made
to obtain a survey in those instances.
The Program Rating of Satisfaction is available in English. Spanish and Creole. Providers are responsible
for reproducing the appropriate survey and providing an envelope (that seals) for each respondent. Ali
responses should be completed in ink •
If a participant cannot read, providers should encourage them to use the same process they use to have
other information read to them. An employee of the 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.
Filling out the form
1) A language appropriate survey and an envelope should be provided to all participants who are required
to complete the form. Only one form per family is required. The form must be filled out in ink.
2) Section II 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 manager
responsible for the client's service delivery. If the survey must be read to the client, the initials of the
staff person performing that function should also be included. In no case should the participant's case
manager read items aloud to the participant.
3) 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 survey.
I) Providers should reassure participants of the confidentiality of their responses. Providers may wish to
Introduce the survey, as follows:
"This survey is one way of helping us deteintine how well we are helping individuals that
come to our agency for assistance. Please take a fe\v minutes after I leave to answer this very
short survey as honestly as possible. Your responses are private and the will not look at them.
Please seal the envelope and give it to me when you are done (or: put it in the drop box)."
5) The completed survey should be placed in the envelope b.,' the recipient and sealed. Providers are
encouraged to provide a "drop box" ‘vith a slot for completed forms.
6) The sealed envelope(s) should be forwarded to the Miami -Dade County Homeless Trust on a monthly
basis.
7) The provider agency should maintain a log of how n-many surveys are distributed.
DETER\1INATIO'v OF MINI;v1UM AVERAGE SCORE FOR
CONSUMER SATISFACTION SUR'El
was intormed of m� n0h[s and resnonsibiuue
BPIRC ecjuiroicnt score
N',a
5
Tx
1 was provided with information about different services
that are available for me
N/A
1. _ b
1 was involved in making decisions about my care/service
plan
11
5.09
I was able to talk with staff when 1 needed to ,,
5.15
The building'and facilities have usually been clean, safe and
comfortable
5.18
My rights were respected and protected, including my right
to file a grievance, if needed
N/A
5.0
'
My case manager seems qualified to help me
1
1 .47
1 would recommend this program to others S
1 5.36
I am treated with respect by the staff 18
1 5.23
The staff seems to care about whether l get better
20
5.31
Program staff were. knowledgeable about available services
that could help me
14
5.38
_
RECOMMENDED 57:00
11 /6/00
JIA III DADS COU TM TRUST
PROGRAM RATING OF SATISFACTION
Section I. :TO BE COMPLETED BY PROGRAM PARTJCIP.--kNI
Instructions: Please answer each question below by placing an /A in the space provided. Your responses to these
questions have no heariq on mar continued phrticination in the prorrrant. ALL responses are cou_jidential.
Why did you choose to enter the program (mark only one box):
0 I decided to come to this program on my own (through outreach. referral. etc.)
0 I was placed here through another program (court intervention, police. etc.) against
0 I had previously participated in this or a similar program and decided to return
OPTIONAL Information:
Name:
Today's Date:
Sex: ❑ male
0 female
Please answer the following questions about the services you received Mark only one hot: which best
describes your feelings about each stateneent. These questions are meant to help us improve the services provided,
so we ask that you tell us howyou really feel, whether or not it is good or bad.
I was informed of my rights and responsibilities,
including the agency's grievance procedures
I was provided with information about different services
that are available for me
Strongly Agree 1 Af ree u Disagree Disagree
Agree I Lime 4 Little
[6) [5] [4] [3J [2]
Strongly
Disagree
[1]
[6] [5] [4] [3) [2] [1]
I was involved in making decisions about my
care/service plan
I was able to talk with staff when 1 needed to
The building and facilities have usually been clean, safe
and comfortable
[6] [1) [a) [3) [2]
[
[6) [s] [4) [=) [') [1]
[6] [5] [4J [=] [-] [l]
My rights were respected and protected, including my
right to file a grievance, if needed -
My case manager seems qualified to help me
I 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 were knowledgeable about available
services that could help me .
[6] [3) [4) 13J [?) [1)
[6) [;) [a] [3) [21
[6) [5) [4l [3] [21
[6) [5]
[4)
[1)
11.1
6] [5] [4] [3] [2J [I)
[6] [5J [4] [3] [?) [I]
Section II.: TO BE COMPLETED BY PROGRAM STAFF
Purpose of Evaluation
Ct At Admission
D At discharge
D Other:
Current Level of Care prot.rded
O emergency housing.
O transitional housing/tx
O transitional housing/non-tv
❑ permanent housing
. 0 services only
Provider Name:
Project Name:
Stair Initials;
Re, I1%6100 roars./pregrarnr3un0
MIAMI-DADE COUNTY HOMELESS TRUST
EVALL'ACION DE LA SATISFACCION CON EL PROGRA IA
Seccion I. COMPLETADA POR EL PARTICIP.NTE DEL PROGR M.A
Instrucciones: Por favor coloque una cot,; [Al err el espacio prof isro parry responder a las prcguntas n cnrrlirruu(ian. Las
respuestas que usted de a este cuestionario rro iir/luirrn de forma algunn sabre lu cnnrinuacion de su participucirin en cite
pro,fratna. TODAS las respucsras se manrendran cottfrdencia/nrerrte.
uPor que decidio usted participar en el programa' (Marque uric casilla solamente):
[ ] Lo decidi por mi cuenta (porque fui remitido o por medio de otro proorama, etc.)
[ ] Fui colocado aqui mediante otro proorama (por intervention de los tribunales, la
,policia, etc.) en contra de mi voluntad
[ ] Ya habia participado en este prooratrla o.en uno similar v decidi regresar
Informacion OPCIONAL:
Nombre y apellido: Genero: M [ J F
Fecha de hoy:
Por favor responda a las pregunras siguientes acerca de los servicios que se le han prestado. Indique con una cru;; [\% EN
UN.9 SOL;4 C4SILLA POR PREGUNT.4 la forma en que risled se sienle acerca de cada una de las cuestiones closerita s.
Como sus respuestas a evils pre:antra nos al'udarrin a mejorar los servicios que prestanros, ie rogan os que nos ha; a saber
coma se sienre en realidad acerca de nuestros servicios, no iurporta si listed los considera bueuos o.nurlos.
Muc de
acuerdo
De
acuerdo
f .Alto de
acuerdo
[ Algo en
desacuerdo
En
desacucrdo
11uv en
desacuerdo
Se me informaron cuales eran mis derechos y
responsabilidades, entre ellos, los procedimientos de la
a encia ara someter ue'as.
[6]
[5)
[4]
[33
[2]
(1)
Se me dio informacion sabre los distintos servicios a los J [6]
que tengo derecho.
[6]
[4]
[3)
[2]
[1)
Participe en la toma de decisiones referentes a mi plan
de atencion y servicios.
[6]
[5]
[4]
[3)
[2]
[1]
Pude hablar con el personal cuando tuve necesidad de
hacerlo.
[6]
[5)
[4)
13]
[2]
[1]
El centro ysus servicios por lo general se han mantenido [6]
lim ios, sin elioro y accesibles.
[5]
[4)
•[3J
[2]
' [1]
Se respetaron y protegieron mis derechos, entre ellos, mi
derecho a someter quejas si lo considera necesario.
[6]
[5)
[4]
[3)
[2]
[1)
Aparentemente, la persona encargada de mi caso Babe to
que tiene que hacer para ayudarme.
[6]
[5]
[4)
[3)
[2]
[1]
Yo les recomendaria este royecto a otras ersonas. 1 [6]
[5]
[4)
[3)
[2]
1i]
Los empleados me trataron respetuosamen te. J [6]
[5)
[4)
[3]
2)
[1)
Apareniernente, a los empleados les interesa que yo
mejore.
[6]
[5]
[4)
[3] •
[2]
[1]
1 Los empleados sabian que servicios pbdia n servirme de
avuda.
(6]
[5)
[4)
[3)
[2]
[ 1]
Seccion I1.: COMPLETADA POR EMPLEADOS DEL PROGRA,MAlcornpleted by program staff)
• Purpose of .Evaluation
0 ,4t Admission
❑ At discharge
•
Other
Current Level of Care provided
• emeroencv housing
- transitional housing/rs
❑ transitional housing norrR
O permanent housing
O services only
1
Provider Name:
Project Name:
Staif Initials:
MIA I-DADi COMITY HOMELESS TRUST
PWOGRAM POI] EVALYE SATISFAKSYON
Section [. TOUT P.ATISIPAN NAN PWOGRAM SIL.A A FFT POU RANPLI PA.] SA .A
Enstriksyon: Tanpri reponn chak keksvon anba la a epi fe yon ti kxia /.�/ Harz espas ki rid la. Rcrronc non bar tyr
pap deranje Jason crap kontinre patisipe Han pwotram silo a. Tout repons yo np sekrc.
POUKJ W CHWAZI PATISIPE NAN PWOGRAM SILA A (fe yon ti kwa Han von
grenn bwat):
Se maven ki chwazi vino Flan program sila a (spa pa referans, swa pa sevis espesyal asistans piblik etc.)
[) Se pa chwa rnwen, se yon lot program ki voyem (zak tribinal, lapolis etc)
J) Mwen te deja patisipe Han yon program konsa epi mwen decide retounnen.
Enfomasyon pou bav si w vle:
Non: Seks ]] Gason j) Fermi
Dat Jodya:
Tanpri reponn keksyon sift) yo dapre sevis w resevwa. Fe you kwa /_r/ Han 1.011 se! ti Aare epi ehrvazi reports ki phis
matche ave w. Keksvon sila-yo la you ede nou bay pi bon sevis, ale rtou nrancle non bay repons ki plis matche ave
w, ke li bon ou pa.
Bon jan
dak6
dako Dak:
tou piti
Pafinn I Pa dako Pa dako
two dako I ditou
Yo fem konnen tout dwa mwen yo ak responsabilite [61 [5] [4] [3] [2) [1)
mwen vo ak kouman pou mwen plenven nan ajans la
Yo te banmwen enfomasyon sou diferan sevis he mwen [6] [5] [41 [3] [21 [1]
kab 'wenn
Mwen te patisipe nan tout desizyon sou planifikasyon I [6] [5) [4] [3] [2) [1]
swen/sevis mwen
Amplwave yo te toujou disponib pou mwen pale avek vo ) [6] [5] [41 [3) [2] (1)
Kote a ak biJding yo te toujou byen pwop, konfotab ak f [6] [ti] [4) [3) [21 [ I ]
bon sekirite
Tout dwa m te respekte ak pwbteje menm dwa m pou
mwen te pore plent si nesese
Moun kap okipe ka mwen an sanble li kalifye pou li
edem
[6) (5) (4] [3] [2) [1)
[6] [p] [4] [3] [2] [1]
Mwen to rekornande pwopram sila a bay lot moun
Amplwaye yotretemwen ak resie
Amplwaye yosanble yo vreman enterese nan mwen
.Amplwaye program la te byen enforne sou tout sevis ki
te disponib pou ede m.
[6] [5] [4
L3) [21 [I]
[6] [-] [4] [31 [2) [I)
[6] [5] [4] [3] [2J [1)
[6] [5] (41 [3) [2] [I]
Section IL: TO BE COMPLETED BY PROGRAM STAFF
Purpose of Evaluation
o At Admission
At discharge
G Other:
Current Level of Care provider!
O emergency housing
O Transitional hou57n2!t>t
O transitional housing%non-tx
❑ FerTnanent housing
C sen ices only
Provider Name:
Project Name:
Staff initials:
Rev ! !r6/00 Fore s oroeramratine