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Page Content
Physical Disability Services Satisfaction Survey Logging
Survey
Date:
First Name:
*
Last Name:
*
Phone Number:
Area Delevopment District:
Barren River
Big Sandy
Bluegrass
Buffalo Trace
Cumberland Valley
FIVCO
Gateway
Green River
Kentucky River
KIPDA
Lake Cumberland
Lincoln Trail
Northern Kentucky
Pennyrile
Purchase
*
County:
Adair
Allen
Anderson
Ballard
Barren
Bath
Bell
Boone
Bourbon
Boyd
Boyle
Bracken
Breathitt
Breckinridge
Bullitt
Butler
Caldwell
Calloway
Campbell
Carlisle
Carroll
Carter
Casey
Christian
Clark
Clay
Clinton
Crittenden
Cumberland
Daviess
Edmonson
Elliott
Estill
Fayette
Fleming
Floyd
Franklin
Fulton
Gallatin
Garrard
Grant
Graves
Grayson
Green
Greenup
Hancock
Hardin
Harlan
Harrison
Hart
Henderson
Henry
Hickman
Hopkins
Jackson
Jefferson
Jessamine
Johnson
Kenton
Knott
Knox
Larue
Laurel
Lawrence
Lee
Leslie
Letcher
Lewis
Lincoln
Livingston
Logan
Lyon
Madison
Magoffin
Marion
Marshall
Martin
Mason
Mccracken
Mccreary
Mclean
Meade
Menifee
Mercer
Metcalfe
Monroe
Montgomery
Morgan
Muhlenberg
Nelson
Nicholas
Ohio
Oldham
Owen
Owsley
Pendleton
Perry
Pike
Powell
Pulaski
Robertson
Rockcastle
Rowan
Russell
Scott
Shelby
Simpson
Spencer
Taylor
Todd
Trigg
Trimble
Union
Warren
Washington
Wayne
Webster
Whitley
Wolfe
Woodford
*
1. When you contacted the Aging and Disability Resource Center, did you speak with a live person?
Yes
No
If No, did you leave a voicemail?
Yes
No
If Yes, when was your call returned?
24 Hours or Less
More Than 24 Hours
No Return Call
Comments:
2. Were they able to assist you and provide you with information on how to apply for services?
Yes
No
Comments:
3. Have you been assigned a case-manager? (If No, skip to question #11)
Yes
No
*
Comments:
4. Do you know how to contact your case-manager if you have questions or need help?
Yes
No
Comments:
5. Have you had any issues reaching your case-manager and does he/she follow up with your requests and needs?
Yes
No
Comments:
6. Has your case-manager helped you find additional services or help that you need?
Yes
No
Comments:
7. Has your case manager provided documents containing the address, phone number, and contact person for the local Area Agency on Aging?
Yes
No
Comments:
8. Overall, how satisfied are you with your case-manager?
Extremely Satisfied
Satisfied
Somewhat Satisfied
Dissatisfied
Other
Comments:
9. Have you tried to contact the agency directly?
Yes
No
If yes, were you able to speak to a live person?
Yes
No
If No, did you leave a voicemail?
Yes
No
If Yes, when was your phone call returned?
24 Hours or Less
More Than 24 Hours
No Return Call
Comments:
10. How satisfied are you with your services through the agency?
Extremely Satisfied
Satisfied
Somewhat Satisfied
Dissatisfied
Other
Comments:
11. Do you receive meals at the senior center or home delivered meals? (If No, skip to question #15)
Yes
No
Comments:
12. Are the meals presented in an appealing manner?
Always
Often
Sometimes
Rarely
Never
Comments:
13. Are you satisfied with the flavor of the food?
Always
Often
Sometimes
Rarely
Never
Comments:
14. Are you satisfied with the variety of food offered throughout the month?
Always
Often
Sometimes
Rarely
Never
Comments:
15. Do you have any additional comments, complaints, or concerns that I have not covered?
Admin
DAIL Staff:
Comments:
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