HOME-DELIVERED MEALS PROGRAM

HOME-DELIVERED MEALS PROGRAM

PARTICIPANT SATISFACTION SURVEY
Directions: Please answer the questions below by placing an X beside your best answer. If you have difficulty, please ask a friend or family member to help you. If you have anything else you want us to know, please write it at the end of the last page or on a separate sheet of paper.
Name

First Name Last Name
How long have you been getting home-delivered meals?
How many days per week do you get home-delivered meals?
Overall, how helpful has it been for you to get home-delivered meals?

Very Helpful Somewhat Not Helpful
Here is a list of goals that home-delivered meals program try to meet. Please rate the program on each goal below.

	Very Good	Good	Fair	Poor	Very Poor
Volunteers who deliver are helpful
The food you receive is
The food tastes good
The food looks good
The menu varies enough from day to day
The temperature of food is (hot foods hot & cold foods cold)

I receive my meal around

By 11:00 AM 12:00 PM After 12:30 PM
If there are any foods you would like to see added to the menu or taken off the menu at your program, please list them below
I would like to add to the menu
I would like taken off the menu
Do you receive information about nutrition with your meals?

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.

	Very Often	Often	Sometimes	Rarely	Never
Read the information
Learned something new from the information
Change your eating habits