CLIENT SATISFACTION QUESTIONNAIRE

Happy Feelings Home Health Care would appreciate you taking the time to complete this Client Satisfaction Questionnaire, as your opinions will help us to meet your expectations concerning the quality of our service.

(Note: Provision of identification information is optional.)

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Please tick “Yes” or “No” for the following questions. Please explain your reason(s) for “No” responses in the “Comments” section at the end of the questionnaire.

1. Did you find us easy to contact?

YesNo

2. Do you feel we responded in a timely manner?

YesNo

3. Did we give you information on the following:- a. Brochure/other documentation about our services b. Service Agreement c. Rights & Responsibilities d. Contact details & numbers within normal office hours e. Contact details & numbers outside normal office hours f. How to make a complaint, including who to contact Elder Abuse Hotline Number

YesNo

4. Were you introduced to, or made aware of the Home Care Worker(s) assigned to you prior to commencement of service?

YesNo

5. Do you feel your needs/wants are being met & are being provided, in accordance with what was agreed upon?

YesNo

6. Was a personal Service Plan developed &implemented?

YesNo

7. Were you/your representative involved in developing the Service Plan?

YesNo

8. Do you feel you are cared for in a comfortable & non discriminatory way?

YesNo

9. How many Home Care Workers are usually involved in your care?

10. Does your Home Care Worker(s) show up for work on time

YesNo

11. Does your Home Care Worker(s) stay for the specified time?

YesNo

12. Does your Home Care Worker(s) assist you with your medication? If “Yes”, give specific details.

YesNoOther

13. Does a Supervisor occasionally make a home visit?

YesNo

14. Are you notified in advance if your Home Care Worker is going to be changed?

YesNo

15. Is there anything that concerns you about your Home Care Worker(s)?

YesNo

16. Were you advised who would be supervising your Home Care Worker(s)?

YesNo

17. Are you notified in advance if your regular services have to be rescheduled?

YesNo

18. Were you advised who you/your representative/family may contact should you wish to speak to someone other than your Home Care Worker(s)?

YesNo

19. Were you advised that we may employ both male & female workers?

YesNo

20. Were you asked if you prefer a male or female worker?

YesNo

21. Is your normal daily routine followed as much as possible within the provision of personal care such as getting up, meal times & bathing arrangements?

YesNo

22. Do you find us to be: Friendly, Considerate, Polite, Respectful, Honest, Believable, Prompt, Dependable, Efficient, Approachable, Financial Matters

23. Do Home Care Workers shop and/or handle money for you?

YesNo

24. If Home Care Worker(s) shop and/or handle money for you, do they always return the change and receipt(s)?

YesNo

25. If Home Care Worker(s) return change and receipts to you, do you both sign the Financial Transactions Record?

YesNo

26. Do Home Care Workers have you sign their Employee Time Sheet after each visit?

YesNo

27. Do you feel we have the required knowledge & skills to deliver service?

YesNo

28. Is there anything you don’t like about our service?

YesNo

29. Have you any suggestions for ways we can improve our service?

YesNo

30. Would you use our services in the future?

YesNo

31. Would you recommend us to others?

YesNo

32. How would you rate the overall quality of service you receive?

PoorFairGoodExcellent

33. How would you rate the Home Care Worker(s) treatment of you?

PoorFairGoodExcellent

34. How do you view the quality of service to its cost?

PoorFairGoodExcellent

Comments

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