Consumer Name
Phone Number
Please enter a valid phone number.
Address
Does your staff arrive to work as scheduled (on time)?
Yes
No
Is your staff arriving to work late every day?
Yes
No
Is your staff courteous at all times?
Yes
No
Are you afraid, intimidated in any way by your staff?
Yes
No
Are there any grievances at this time?
Yes
No
If "yes" brief description:
While delivering hands on support, does your staff talk on his/her cell phone?
Yes
No
Does your staff leave for long extended periods of time without notifying you?
Yes
No
Are you satisfied with your current PCA Provider, Veterans at Home Care?
Yes
No
If "no" brief description:
Is there any area of the Agency you could improve, what would be that area and why?
What grade would you give to your DSW? 1 being the lowest and 10 being the highest?
1
2
3
4
5
6
7
8
9
10
Additional Comments:
Consumer Signature
Date
/
Month
/
Day
Year
Date
Legal Guardian Signature (If Applicable)
Date
/
Month
/
Day
Year
Date
VAHC Representative Signature
Date
/
Month
/
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
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