Attachment B-6: Homemaker Services | ADMINISTRATION-5600-MANUAL

Item #	HCBS Homemaker Services Survey Questions	Answer Options
	How often do the following occur?	Always Sometimes Never
1.	My Homemaker treats me with respect.
2.	I am satisfied with the time my Homemaker is scheduled to arrive.
3.	My Homemaker is very thorough in doing her/his job.
4.	My Homemaker stays the full amount of time that is agreed upon in my Care Plan.
5.	I was offered a substitute Homemaker when the regular Homemaker could not come.
6.	Do the Homemaker Services you receive help you to continue to be able to live at home?	Yes No
7.	Are these Homemaker Services effective in helping you in your everyday life?
8.	Overall, how satisfied are you with the Homemaker Services you receive?	Satisfied Somewhat Satisfied Dissatisfied
9.	Who would you contact first if you had a problem with the Homemaker Services?	Homemaker’s Supervisor or Agency Area Agency on Aging Division of Aging Services Do Not Know Others:
10.	In your opinion, how could we improve Homemaker Services for you? Please mark all that apply.	Need the same Homemaker each time. Need better trained Homemakers. I would like to choose my Homemaker. Need the Homemaker to do more for me. Need the Homemaker to arrive on time as scheduled. Need the Homemaker for more hours and/or more days. Need the Homemaker to do things the way I want them to be done.
11.	Please tell us any other suggestions you have to improve the quality of the Homemaker Services you receive.	Comments:

Item #

HCBS Homemaker Services Survey Questions

Answer Options

How often do the following occur?

Always
Sometimes
Never

My Homemaker treats me with respect.

I am satisfied with the time my Homemaker is scheduled to arrive.

My Homemaker is very thorough in doing her/his job.

My Homemaker stays the full amount of time that is agreed upon in my Care Plan.

I was offered a substitute Homemaker when the regular Homemaker could not come.

Do the Homemaker Services you receive help you to continue to be able to live at home?

Are these Homemaker Services effective in helping you in your everyday life?

Overall, how satisfied are you with the Homemaker Services you receive?

Satisfied
Somewhat Satisfied
Dissatisfied

Who would you contact first if you had a problem with the Homemaker Services?

Homemaker’s Supervisor or Agency
Area Agency on Aging
Division of Aging Services
Do Not Know
Others:

10.

In your opinion, how could we improve Homemaker Services for you? Please mark all that apply.

aaa

Need the same Homemaker each time.
Need better trained Homemakers.
I would like to choose my Homemaker.
Need the Homemaker to do more for me.
Need the Homemaker to arrive on time as scheduled.
Need the Homemaker for more hours and/or more days.
Need the Homemaker to do things the way I want them to be done.

11.

Please tell us any other suggestions you have to improve the quality of the Homemaker Services you receive.

Comments:

If the survey is to be administered by mail, please do not ask the consumer to identify him/herself, unless he or she wishes to be contacted for follow-up. Add lines at the end of the survey for the consumer to indicate voluntarily a desire for a contact and to provide his or her name and telephone contact information.