Appendix 322-A A Friendly Visiting Program Survey | HCBS-5300-MANUAL
|
Georgia Division of Aging Services |
|||
Chapter: |
300 |
Effective Date: |
10/27/2021 |
|
Section Title: |
A Friendly Visiting Program Survey |
Reviewed or Updated in: |
MT 2016-05 |
|
Section Number: |
Appendix 322-A |
Previous Update: |
MT 2016-05 |
|
Friendly Visiting Program Satisfaction Survey
Thank you for taking the time to complete this survey. We would like to know how the Friendly Visitor who has been visiting you has affected your life. All information will be kept confidential; please do not disclose your name. You may choose not to answer questions.
Please rate how strongly you agree or disagree with each of the following statements by placing an X in the appropriate box.
| Strongly Disagree | Disagree | Neither Agree nor Disagree | Agree | Strongly Agree | |
|---|---|---|---|---|---|
1. Because I have a Friendly Visitor visiting me, I feel like someone cares how I’m doing. |
☐ |
☐ |
☐ |
☐ |
☐ |
2. Because I have a Friendly Visitor visiting me, I feel less lonely. |
☐ |
☐ |
☐ |
☐ |
☐ |
3. Because I have a Friendly Visitor visiting me, I feel I have close ties to more people. |
☐ |
☐ |
☐ |
☐ |
☐ |
4. I feel safer knowing someone will check on me. |
☐ |
☐ |
☐ |
☐ |
☐ |
5. I look forward to the visits. |
☐ |
☐ |
☐ |
☐ |
☐ |
6. Overall, I am satisfied with my Friendly Visitor. |
☐ |
☐ |
☐ |
☐ |
☐ |
7. Overall, this Friendly Visiting program has met my expectations |
☐ |
☐ |
☐ |
☐ |
☐ |
Think about the Friendly Visiting service that you receive. Please tell us how satisfied you are with the following statements by placing an X in the appropriate box.
| Not Satisfied | Satisfied | Very Satisfied | |
|---|---|---|---|
8. With the time visits are made. |
☐ |
☐ |
☐ |
9. That visits are made as scheduled. |
☐ |
☐ |
☐ |
10. That the service is meeting your needs? |
☐ |
☐ |
☐ |
Please offer any suggestions and/or comments: