Consumer Focus Indicators

. A D NS     1.  I felt my health needs, preferences and special circumstances were considered.

. A D NS     2.  I felt I was an active partner in the process.

. A D NS     3.  The Gateway (access system) representative listened to feedback from me or my family.

. A D NS     4.  I felt the potential public and private (self pay) support service options were discussed.

. A D NS     5.  I felt I was able to make a better decision about my services or care (or my family member’s) as a result of the information and assistance I received.

Efficiency Indicators

. A D NS     1.  I felt the time (beginning to end) to complete the process was efficient.

. A D NS     2.  I didn’t feel I had to make too many repeat calls or trips to the agency.

. A D NS     3.  I felt the agency representatives were competent and helped speed the process.

. A D NS     4.  I felt I received the most appropriate services in the right settings.

Awareness/Trust Indicators

. A D NS     1. I could find the agency telephone number and had no trouble locating the office (if visited personally.)

. A D NS     2.  I felt the information provided was easy to understand and covered what I needed to know.

. A D NS     3.  I would be comfortable and confident in calling the agency again.

. A D NS     4.  I would recommend the agency to a friend.

Responsiveness Indicators

. A D NS     1.  The agency staff person who assisted me treated me pleasantly and in an appropriate manner.

. A D NS     2. The agency staff person listened to my concerns.

. A D NS     3.  Neither I nor any member of my family felt frustrated with the agency staff or process.

. A D NS     4.  I received clear instructions and answers to all my questions.

General Satisfaction Indicators

. A D NS     1.  Did you have any difficulty locating the agency telephone number or locating the office?

. A D NS     2.  Did the representative who assisted you treat you pleasantly and in an appropriate manner?

. A D NS     3.  Did you feel your health needs, preferences and special circumstances were considered?

. A D NS     4.  Did you feel the time needed to complete the process was adequate and efficient?

. A D NS     5.  Were you satisfied with the assistance you received and your overall health or social service outcomes?

Are there any comments you would like to add?