Client Satisfaction Survey
Case Management and Medical Care
Agency: ______Date: ______
Which programs have you received services from in the past six months (mark all that apply):
____ADAP _____ AICP _____ HOPWA ______Ryan White Medical ______Peer Program
_____ Ryan White Case Management
Overall my satisfaction with Ryan White services is:
__Very Satisfied __ Somewhat Satisfied __ Undecided __ Somewhat Dissatisfied __ Very Dissatisfied
Case Management - Please check up to 3 of the following case management services or aspects of service provision you are MOST pleased with:
___ ADAP___ Appointment Times___ Dental Care
___ AICP___ Treated with Respect___ Care Plan Meets My Needs
___ HOPWA___ Emergency Planning___ Assistance with Medications
___ Confidentiality___ HIV Prevention Education___ Wait Time at Appointment
___ Referral Assistance___ Transportation___ Services Provided in My Language
___ Calls Returned Promptly___ HIV Disease Education___ Mental Health
___ Peer Program
Comments:
Case Management - Please check up to 3 of the following case management services or aspects of service provision that you feel could be improved:
___ ADAP___ Appointment Times___ Dental Care
___ AICP___ Treated with Respect___ Care Plan Meets My Needs
___ HOPWA___ Emergency Planning___ Assistance with Medications
___ Confidentiality___ HIV Prevention Education___ Wait Time at Appointment
___ Referral Assistance___ Transportation___ Services Provided in My Language
___ Calls Returned Promptly___ HIV Disease Education___ Mental Health
___ Peer Program
Comments: (Please explain what improvement you would like to see for items checked)
Medical Care - Please check up to 3 of the following medical services or aspects of service provision you are MOST pleased with:
___ Nurse Case Management___ Appointment Times___ Ability to Get Acute Care Appointments
___ Medical Care___ Treated with Respect___ Medical Plan for care meets my needs
___ Medication Education___ Emergency Planning___ Assistance with Medications
___ Confidentiality___ HIV Disease Education___ Wait Time at Appointment
___ Referral Assistance___ Lab Services___ Services Provided in My Language
___ Calls Returned Promptly___ Mental Health___ Peer Program
Comments:
Medical Care - Please check up to 3 of the following medical services or aspects of service provision you feel could be improved:
___ Nurse Case Management___ Appointment Times___ Ability to Get Acute Care Appointments
___ Medical Care___ Treated with Respect___ Medical Plan for care meets my needs
___ Medication Education___ Emergency Planning___ Assistance with Medications
___ Confidentiality___ HIV Disease Education___ Wait Time at Appointment
___ Referral Assistance___ Lab Services___ Services Provided in My Language
___ Calls Returned Promptly___ Mental Health___ Peer Program
Comments: (Please explain what improvement you would like to see for items checked)
The Health Planning Council of Southwest Florida, Inc. (HPCSWF) would like to thank you for your participation in this survey. The information given will help HPCSWF improve services to persons living with HIV/AIDS in our community. Please send this survey back to us in the self-addressed, stamped envelope provided to you. All information from individual questionnaires will be kept confidential. Your answers will be kept anonymous and used for statistical purposes ONLY.
May 2012