1 Client Survey

SENIOR COMPANION PROGRAM

INDEPENDENT LIVING PERFORMANCE MEASURE SURVEY

Thank you for taking the time to complete this survey. We would like to know how the Senior Companion Volunteer who has been assisting you has affected your life.

All information will be kept confidential; please do not disclose your name. You may choose not to answer questions.

This 1st question is about how many hours of service you receive in a typical week from your senior companion.

Tell us how many TOTAL HOURS in a typical week you received services.

Here is an example of how Mrs. Jones would answer question #1:

Her Senior Companion usually spends one hour on Monday with Mrs. Jones and two hours on Wednesday. Therefore, the total hours a week that she receives services is 3 hours a week.

1. In a typical week, my Senior Companion Volunteer is with me for

hours

Please turn the page for the questions 2-13

Because I Have a Senior Companion Volunteer …

	Strongly Disagree	Somewhat Disagree	Somewhat Agree	Strongly Agree
… I feel less lonely.	1	2	3	3
… I feel I have close ties to more people.	1	2	3	4
… I am able to do more of the things I need to do.	1	2	3	4
… I am able to do more of the things I want to do.	1	2	3	4
… I can remain living in my own home.	1	2	3	4
… I am eating regularly scheduled meals.	1	2	3	4
… I am able to take care of other necessary errands/appointments.	1	2	3	4
…I am able to get to medical appointments.	1	2	3	4
… I am more satisfied with my life.	1	2	3	4
… I am able to get to the grocery store.	1	2	3	4
Overall, I am satisfied with my Senior Companion volunteer.	1	2	3	4
Overall, the Senior Companion Program has met my expectations.	1	2	3	4

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OMB Control Number: 3045-0146 Expires: 10/31/2015