Client Satisfaction Survey
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you find out about BRCA program(s)?
*
Please Select
TV
Internet
Social Media
Family
Friend
Other
If other, please answer here
Which program did you receive services from?
*
Please Select
Adult Day Care
CIRCLES
Congregate Nutrition
CHDO
Day Care
Early Head Start
Emergency Assistance Program
Foster Grandparent
Google
Head Start
Home Delivered Meals
SCSEP
Self-Sufficiency
VITA
Weatherization / HARRP
Rows
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
Was the BRCA staff responsive to your inquiries?
Was the BRCA staff knowledgeable about the program you requested?
Did you receive information about other services you may have been interested in?
Was the process, from application to receipt of services, easy to understand?
Have the services you received impacted you and your family?
How would you rate your overall interaction with BRCA?
Would you recommend BRCA services to family or friends?
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Yes
No
If no, What concerns do you have about BRCA?
How long have you been getting home-delivered meals?
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How long have you been getting home-delivered meals?
*
Less than 1 year
1-3 years
3-5 years
5-8 years
8-10 years
10-15 years
Over 15 years
How many days per week do you get home-delivered meals?
*
Which Route?
Please Select
GRANITE FALLS-A
GRANITE FALLS-B
GAMEWELL
MLK 11
MLK 13
MLK 13-2 (KOINONIA)
MLK 14
WHITNEL
Overall, how helpful has it been for you to get home-delivered meals?
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Very Helpful
Somewhat
Not Helpful
Here is a list of goals that the Home-Delivered Meals Program tries to meet. Please rate the program on each goal below.
*
Rows
Very Good
Good
Fair
Poor
Very Poor
How would you rate the volunteers that deliver your meals?
How would you describe the food that you receive?
How would you describe how the food looks?
How would you describe how the food tastes?
How would you describe the variety of the menu options each day?
How would you describe the accuracy of the temperature of the food? (is the hot food hot or the cold food cold)
I receive my meal around
*
by 11:00 am
12:00 pm
12:30 pm
Is there any food that you would like to see be added to the menu?
*
Is there any food that you would like to see be removed from the menu?
*
Do you receive information about nutrition with your meals?
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Very Often
Often
Sometimes
Rarely
Never
If you receive information about nutrition, please check the best answers below to tell us how you use it.
*
Rows
Always
Sometimes
Never
Do you read the information given to you?
Have you learned anything new from the information?
Have you changed any of your eating habits because of any of the information that you read?
Do you think the Home-Delivered Meals Program can be improved?
*
Yes
No
If yes, What improvements do you feel could be made for the home delivered meals program?
Here is a list of goals that the congregate nutrition sites try to meet. Please rate the program on each goal below
*
Rows
Very Good
Good
Fair
Poor
Very Poor
The food you receive is
How would you describe how the food looks?
How would you describe how the food tastes?
How would you describe the variety of the menu options each day?
How would you describe the accuracy of the temperature of the food? (is the hot food hot or the cold food cold)
Is there any food that you would like to see be added to the menu?
*
Is there any food that you would like to see be removed from the menu?
*
Is the congregate nutrition contribution box made available to you?
*
Yes
No
What do you feel is a fair contribution amount?
*
Please rate the activities at the congregate nutrition sites
*
Rows
Yes
No
No Response
Are you satisfied with the activities at the site?
Do you participate in the craft activities at the site?
Do you participate in the exercise program activities at the site?
Do you receive nutrition education at least once a quarter?
What are your favorite activities at the site?
*
What type of activities would you like to see at the site?
*
Please answer these general questions about the congregate nutrition sites
*
Rows
Yes
No
No Response
Do you feel free to make suggestions at the site?
Do you think site rules and policies are reasonable?
Are you satisfied with operating hours?
Do you feel that the site is clean?
Please rate the site manager in the following areas:
*
Rows
Very Good
Good
Fair
Poor
Very Poor
How would you describe the helpfulness of the site manager?
How would you characterize the site manager's politeness towards all the members on the site?
How would you describe the fairness of the site manager in their interactions with all the site members?
Please answer these general questions about the auditor/inspector
*
Rows
Yes
No
No Response
Was the auditor/inspector on time for the assessment?
Was he/she courteous during the assessment?
Did the auditor/inspector answer questions to your satisfaction?
If no what questions do you currently have?
Please answer these general questions about the contractor
*
Rows
Yes
No
No Response
Was the contractor(s) on time for their appointment(s)?
Was the contractor courteous?
Did the contractor do everything possible to keep their workspace clean?
Is there anything that has not been done to your satisfaction?
If yes, what needs to be done so that you would be completely satisfied?
Please answer these general questions about your overall experience with the Weatherization services your received
*
Rows
Yes
No
Not Yet
Have you noticed energy savings as a result of the work?
Has there been a reduction in your energy bill?
Did you receive a refrigerator? (do not ask unless told)
Do you need to make any changes to your personal information since your last assessment?
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