Attachment_H-_Client_Satisfaction_Form_(Sample).pdf

Please return to:

IMCOM G-9, Family & MWR Programs 2255 Reynolds Road, Bldg 2266 JBSA Fort Sam Houston, TX 78234-1222

EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP)

RESPITE CARE EVALUATION FORM

Your name (optional):

Approximate period or dates of respite care:

Care giver's name:

1 = Unnacceptable 2 = Marginal 3 = Acceptable 4 = Good 5 = Excellent

1. How would you rate your care giver's availability and accountability for meeting work schedules?

1 2 3 4 5

2. How would you rate your care giver's communication efforts?

1 2 3 4 5

3. How would you rate your care giver's level of interaction and support, including understanding of family concerns or difficulties?

1 2 3 4 5

Attachment H Client Satisfaction Form (Sample) amber.m.large Line

4. How would you rate your caregiver's level of professionalism?

1 2 3 4 5

1 = Unacceptable 2 = Marginal 3 = Acceptable 4 = Good 5 = Excellent

5. What is your opinion of the respite care personnel?

1 2 3 4 5

6. Rate the overall program.

Positive/negative comments, customer complaints, or suggestions for improvement

Attachment H Client Satisfaction Form (Sample) amber.m.large Line