Supportive Services for Veteran Families Program

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DEPARTMENT OF VETERANS AFFAIRS
SUPPORTIVE SERVICES FOR VETERAN FAMILIES (SSVF) PROGRAM
PARTICIPANT SATISFACTION SURVEY

Number of individuals (including yourself) in household receiving support services from this provider:
1	2	3	4+

Are you enrolled in the VA health care system?
Yes	No

Were you enrolled in VA health care system prior to receiving services from this provider? 
Yes	No

    1. How would you rate the quality of the services you have received from this supportive services provider?
Extremely Poor		Below Average		Average 	Above Average		Excellent

    2. Did the supportive services provider involve you in creating an individualized housing stabilization plan?
Yes	No
4A. If you answered Yes to Question 5, do you feel that this housing plan is a good fit for your needs?
Yes	No

    3. In the following table, please indicate which supportive services you received and indicate the quality of the supportive services received.
Supportive Services
Did you need this service?
Did you receive this service?
What was the quality of service?
1. Case Management
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
2. Assistance in obtaining VA Benefits
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
3. Assistance in obtaining and coordinating other public benefits
a. Health care
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
b. Daily living
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
c. Personal financial planning
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
d. Transportation
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
e. Income support
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
f. Legal
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
g. Child care
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
h. Housing counseling
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
4. Other Supportive Services
a. Rental Assistance
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
b. Utility fee payment assistance
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
c. Security and utility deposits
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
d. Moving costs
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent
e. Purchase of emergency supplies
Yes
No
Yes
No
Extremely Poor
Below Average
Average
Above Average
Excellent

    4. How many times have you moved since you started receiving services from this provider?
    0 1 	2	3+
    5. Since you started receiving services from this supportive services provider, was there a time when your income decreased so much that it became hard to pay your housing costs?
	Yes	No
    6. How satisfied are you with the courteousness of the staff person that you initially spoke with when you contacted the provider? (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied) 

    7. How satisfied are you with the courteousness of the staff person that you dealt with most often while you were working with this provider? (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied) 

    8. How satisfied are you with the timeliness of communication with the staff person that you dealt with most often while you were working with this provider? (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied) 

    9. If your experiences were positive with this supportive services provider, please tell us why. 

    10. If your experiences were negative with this supportive services provider, please tell us why. 

Please list any additional suggestions as to how to improve the SSVF Program.