Survivor Satisfaction Survey – Survivor

O MB Control No:

Expiration Date:
Estimated Burden: 15 Minutes

Disaster Human Services Case Management – Survivor Satisfaction Survey

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to enable ACF/OHSEPR to identify a disaster survivor’s unmet needs and provide case management support that can connect a disaster survivor to services that meet their needs. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is XXXX-XXXX and the expiration date is XX/XX/20XX. If you have any comments on this collection of information, please contact the Office of Human Services Emergency Preparedness and Response, 330 C St. SW, Washington, D.C. 20201.

Thank you for participating in the Disaster Human Services Case Management Program. We would like to ask you a few questions about your experience. Your responses will help us improve the Program and support other disaster survivors like you. Participation in the survey is voluntary. Your answers will not negatively impact the services that you receive.

Enter Name or Location of Disaster:

I received Disaster Human Services Case Management Services for:

☐ 30 days or less ☐ 31 – 60 days ☐ 61 – 90 days ☐ More than 90 days

My case manager provided referrals for (select all that apply):

☐ Behavioral Health ☐ Child Care ☐ Clothing ☐ Disability

☐ Elder Care ☐ Employment ☐ Federal Disaster Assistance

☐ Financial Assistance ☐ Food Assistance ☐ Health Insurance ☐ Housing – Short-term

☐ Housing – Long-term ☐ Legal Services ☐ Medical ☐ Pharmacist

☐ State human services ☐ Veteran assistance ☐ Other________________

Please describe your experience.

	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
My case manager treated me with respect	☐	☐	☐	☐	☐
My case manager helped me identify my needs	☐	☐	☐	☐	☐
My case manager actively involved me in the development of my case management plan	☐	☐	☐	☐	☐
My case manager helped me find services I needed	☐	☐	☐	☐	☐
My case management plan will help me recover from the disaster	☐	☐	☐	☐	☐

If you answered Disagree or Strongly Disagree to the questions above, please explain why:

Thank you very much for your time and cooperation. Your responses have been very helpful to us.