Annual Individual Satisfaction Audit

Full Name*

First Name Last Name

Achieve Community Services (ACS) will provide assistance with completing this survey upon request and in a mode of communication agreeable or preferred by the individual.

I understand the purpose of this survey is to ensure that I receive the best possible services. My answers will not be used in a negative way by ACS. If the quality of my services change upon completion of this survey in an unsatisfactory manner, I understand it is within my rights to contact my Program Coordinator, Case Manager, Legal Representative, and/or BDDS to file grievance, and/or to change services providers.

Initial*

Individual Is*

Independently able to communicate answers to questionsNon-communicative and requires assistance

If the individual is Non-communicative, indicate the person acting as respondent to the survey*

Direct Care ProfessionalFamily MemberGuardian

ACS representatives have informed me of my right to choose another provider at any time*

TRUEFALSE

Please rate from 1 to 5 on the mentioned survey parameters. * Poor = 1 ; Acceptable = 3 ; Excellent = 5 This questionnaire is issued on a rating system from 1(poor) to 5 (excellent), 3 being an acceptable level of service. Please select the number, which most accurately reflects your satisfaction level

ACS Direct Care Professionals (DCP) provide safe and reliable assistance and transportation to my scheduled appointments*

	1	2	3	4	5

1 is Poor, 5 is Excellent

ACS DCP administers my medication effectively, consistently, and as prescribed*

	1	2	3	4	5

1 is Poor, 5 is Excellent

ACS works effectively with other members of my support team to assist me with achieving activities and goals I enjoy and want to do*

	1	2	3	4	5

1 is Poor, 5 is Excellent

ACS works effectively with other members of my support team to assist me with establishing and achieving my personal outcomes for a fulfilling life*

	1	2	3	4	5

1 is Poor, 5 is Excellent

ACS DCP ensures that I am assisted with my residence being maintained in a safe and sanitary condition that meets my daily needs*

	1	2	3	4	5

1 is Poor, 5 is Excellent

I believe ACS DCP assists me with keeping my home clean and sanitized*

	1	2	3	4	5

1 is Poor, 5 is Excellent

ACS Administrative Support Team is available regularly and will assist with resolving any issues I have with my DCP*

	1	2	3	4	5

1 is Poor, 5 is Excellent

ACS DCP and Administrative Support Team assists me with interacting and associating with individuals of my choice*

	1	2	3	4	5

1 is Poor, 5 is Excellent

I am regularly provided choices to participate in the activities and visitation of locations I wish*

	1	2	3	4	5

1 is Poor, 5 is Excellent

I am allowed to choose when I go into the community for activities*

	1	2	3	4	5

1 is Poor, 5 is Excellent

ACS DCP and Administrative Support Team respects my privacy and upholds my rights thereto with regards to opening my own personally addressed mail, personal telephone calls and conversations, utilizing the restroom, accessing my bedroom, and at any other identified point in time that I may request it*

	1	2	3	4	5

1 is Poor, 5 is Excellent

ACS protects my right to have access to my personal possessions when DCP is present*

	1	2	3	4	5

1 is Poor, 5 is Excellent

ACS, as an organization upholds a mission statement, goals, policies, and procedures to ensure that they incorporate principles and practices that promote cultural diversity and cultural competence*

	1	2	3	4	5

1 is Poor, 5 is Excellent

ACS Administrative Support Team and DCP regularly communicate with me in a respectable manner and in my preferred method of communication*

	1	2	3	4	5

1 is Poor, 5 is Excellent

How would you rate your satisfaction with the performance, reliability, communication, and competency of ACS DCP*

	1	2	3	4	5

1 is Poor, 5 is Excellent

How would you rate your satisfaction with the performance, reliability, communication, and competency of ACS Administrative Support Team?*

	1	2	3	4	5

1 is Poor, 5 is Excellent

Do the services provided by ACS meet and exceed your family’s needs? *

	1	2	3	4	5

1 is Poor, 5 is Excellent

How can ACS further improve your services and assist you with achieving your personal vision for a complete and fulfilling life?

Additional Comments

Individual or Respondent Name*

Date*

Date

Individual or Respondent Signature*

Clear

ACS Representative

Clear

Annual Individual Satisfaction Survey