Stakeholder Survey

Dear stakeholder, Thank you for the opportunity to serve children and youths referred by your agency! Please answer the six questions of our survey and fax the completed form to 404.761.0720, feel free to use additional pages for more comments if needed. We appreciate your specific feedback and suggestions these comments will help us improve our performance as an intensive in-home services provider as well as your community partner. Thanks again and best regards, Your JIREH team STAKEHOLDERS’ SATISFACTION SURVEY Date: _________________________ Respondent:____________________________ Agency/Organization: _______________________ 1. How would you rate a quality of introduction to our services you received before you started using our services (consider e.g., completeness and accuracy of informational session) Low 1 2 3 4 5 High Please explain. What we can do to improve our performance in this criterion? _________________________________________________________________________________________ _________________________________________________________________________________________ 2. How would you rate the quality of our services (consider e.g., good relationship with clients, addressing appropriate problems with clients, linking them other resources)?

Low

1

2

3

4

5 High

Please explain. What we can do to improve our performance in this criterion? _________________________________________________________________________________________ _________________________________________________________________________________________ 3. How would you rate the professional behavior of our staff (e.g., staff integrity, competency, returning phone calls within 24 hours, proper dress code, using the proper language)?

Low

1

2

3

4

5 High

Please explain. What we can do to improve our performance in this criterion? _________________________________________________________________________________________ _________________________________________________________________________________________ 4. How would you rate skills/knowledge/expertise of our clinical and administrative staff?

Low

1

2

3

4

5 High

Please explain. What we can do to improve our performance in this criterion? _________________________________________________________________________________________ _________________________________________________________________________________________ 5. How would you rate the quality and timeliness of our paperwork (please consider completeness, accuracy, relevancy, on-time submission, reporting period)

Low

1

2

3

4

5 High

Please explain. What we can do to improve our performance in this criterion? _________________________________________________________________________________________ _________________________________________________________________________________________ 6. Are there any additional services that you would like to see us providing? If yes, which ones?

__________________________________________________________________________________ __________________________________________________________________________________

Fax to 404. 761. 0720 QI103-Stakeholder Satisfaction Survey

Est. Mar 2008