APS Client Questionnaire

OMB Control Number 0985-xxxx

Expiration Date: xx/xx/xx

CLIENT QUESTIONNAIRE

Dear Client,

If you are completing the form yourself: The study team at New Editions Consulting would appreciate your feedback about your most recent interaction with [name of APS Program]. [Description of APS program and types of services to cue the respondent, to the greatest extent possible, into answering the questions based on their experience with APS, rather than other services they may be receiving]. Please take a few minutes to answer all of the questions on the next page by marking the rating that best matches your opinion. Please choose only one answer per question. Then, place the completed form in the pre-paid envelope and mail it to us. By submitting the form, you are agreeing to, or giving your consent, for your answers to become a part of our study. Your feedback will help us improve our work and will be kept completely private. Thank you for sharing your feedback!

If you are completing the form on behalf of the APS client: ACL would appreciate your feedback about the client’s most recent interaction with [name of APS Program]. [Description of APS program and types of services to cue the respondent, to the greatest extent possible, into answering the questions based on their experience with APS, rather than other services they may be receiving]. Please take a few minutes to answer all of the questions on the next page by marking the rating that you think best match the client’s opinion (put yourself in the client’s shoes). Please choose only one answer per question. Then, place the completed form in the pre-paid envelope and mail it to us. By submitting the form, you are agreeing to, or giving your consent, for your answers to become a part of our study. Your feedback will help us improve our work and your answers will be kept completely private. Thank you for sharing your feedback!

[Signature]

Public Burden Statement

According to the Paperwork Reduction act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reading instructions and responding to questions. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201, attention Stephanie Whittier Eliason, Administration for Community Living, Mary E. Switzer Room 1132A or email [email protected] and reference the OMB Control Number 0985-xxxx.

[8-Digit Form Number]

Please answer all of the questions below by marking the rating that best matches your opinion/the opinion of the client. Please choose only one answer per question.

Statement	Yes	No
In the past year, is this the only time you’ve worked with [name of APS Program]?	□	□

Statement	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
When I first encountered [name of APS Program], I thought I needed their help.	□	□	□	□	□
I helped decide what type of help I received.	□	□	□	□	□
I felt that the worker respected my wishes about what would help me.	□	□	□	□	□
I received all the services I needed.	□	□	□	□	□
I’m satisfied with the help I received from [name of APS Program].	□	□	□	□	□
I feel safer because of the help I received from [name of APS Program].	□	□	□	□	□
I feel like my life is better because of the help I received from [name of APS Program].	□	□	□	□	□

9. Please let us know if you would like to share anything else about your experience with [name of APS Program].

______________________________________________________________________________

Who completed this form? □ Myself (client) or □ Someone on behalf of the client