Today's Date
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Month
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Day
Year
Date
Which SELF office did you most recently visit?
Hamilton Office
Middletown Office
Ohio Means Jobs
None, I received services remotely (email/phone/home)
N/A (I have not received services)
Which service or program did you use most recently from SELF?
Rent assistance through the COVID-19 relief program
HEAP, PIPP, or other energy bill (electric/natural gas) or water bill assistance
Home repair services
Weatherization services
Vehicle repair services
Build-Up Academy educational program
Getting Ahead educational program
IDA educational program
Jobs Now educational program
Microenterprise/Microloan educational program
None/does not apply to me
How has this service improved your personal/professional/family situation(s)?
How did you find out about this service or program?
From another SELF service or program
Referred from another agency
Heard about it from a friend or other person
Social media (Facebook, Twitter, etc)
Searched online
Other
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Home Repair Program
Your Name
Your Address
Tell us the repairs that were completed for you.
Is there any trash/debris that needs to be removed from the job site?
Please Select
Yes
No
Are there any materials or tools that need to be picked up?
Please Select
Yes
No
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Overall, how satisfied are you with the services you most recently received from SELF?
1. Not satisfied at all
2. Somewhat not satisfied
3. Neutral
4. Somewhat satisfied
5. Completely satisfied
Select one:
I was able to get an appointment within 30 days.
I was NOT able to get an appointment within 30 days.
Not applicable/unsure
Select one:
SELF staff treated me with courtesy and respect.
SELF staff did not treat me with courtesy and respect.
Not applicable/unsure
Staff Appreciation: Was anyone at SELF especially helpful? Please let us know:
Do you have any concerns or suggestions for SELF?
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Which service(s) or program(s) have you ever used from SELF?
Rent assistance through the COVID-19 relief program
HEAP, PIPP, or other energy bill (electric/natural gas) or water bill assistance
Home repair services
Weatherization services
Vehicle repair services
Build-Up Academy educational program
Getting Ahead educational program
IDA educational program
Jobs Now educational program
Microenterprise/Microloan educational program
None/does not apply to me
What are the greatest needs for your household? (Pick three)
A job/better employment
Food
Childcare
Home repairs
Homebuyer education
Homeless shelters
Housing that is affordable
Violence prevention
Mental health and wellness programs
Drug/alcohol addiction recovery assistance
Better healthcare
Rent payment assistance
Utility payment assistance
Public transportation (bus, taxi, etc.)
Affordable personal vehicle or personal vehicle repair
Career exploration assistance
Small business set-up and support
College degree, job certification, or other career education
Support groups and workshops for getting ahead
Help creating a budget or financial plan
Where do you live?
Fairfield City
Fairfield Township
Hamilton
Hanover Township
Lemon Township
Liberty Township
Madison Township
Middletown
Milford Township
Monroe
Morgan Township
Oxford
Reilly Township
Ross Township
St. Clair Township
Trenton
Wayne Township
West Chester
How has the repair of your vehicle improved your personal/professional/family situation(s)?
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Your Contact Information
Would you like to speak to someone from SELF about this survey?
*
Please Select
No
Yes, please contact me.
If you select "yes" we will contact you within seven business days.
Your Name:
*
This field is required only if you indicated that you would like us to contact you.
Your Phone Number
*
This field is required only if you indicated that you would like us to contact you.
Format: (000) 000-0000.
May we text this number to contact you?
Please Select
Yes, you may text this number
No, do not text this number
Your Email Address
*
This field is required only if you indicated that you would like us to contact you. If you do not have email, you can write none@none.com
May we send you occasional information about SELF (such as our email newsletter)?
Please Select
Yes - add me to the email news
No - do not send these emails
Submit
Should be Empty: