7a Client Feedback Survey - English

DVHCP DV Site

CLIENT FEEDBACK SURVEY

We are trying to improve the care we provide to women. Please take a few minutes to answer the following questions. You can skip questions you do not want to answer. This is completely voluntary and will not affect the care you receive here. Please do not write your name on this. It is completely private – no names attached. For your answers to be most helpful, please be as honest as you can. THANK YOU!

1. Did your advocate ask you about whether you need health services?

No Yes Don’t Know

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2. Did your advocate give you either one of these palm-sized cards (pictured below)?

No Yes Don’t Know

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3. Did receiving this card or other information from your advocate increase your understanding about how being treated badly in your relationships can affect your health?

No Yes Don’t Know Not applicable, I did not receive the card

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4. How helpful or unhelpful was it to be asked about your healthcare needs? Please circle a number below:

0	1	2	3	4	Not Applicable
Not Helpful				Very Helpful	

5. How helpful or unhelpful was it to learn about the availability of local healthcare services? Please circle a number below:

0	1	2	3	4	Not Applicable
Not Helpful				Very Helpful	

6. After learning about the availability of local healthcare services, have you used any services?
   No Yes

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7. How likely are you to use these local healthcare services in the future? Please circle a number below:

0	1	2	3	4	Not Applicable
Not likely				Very likely	

8. What is your age? Are you:

10 to 24 years old 25 and over

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Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0212. Public reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857.