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In Home Services Satisfaction Survey
FIVCO AAAIL - Homecare Client Survey
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How long have you been receiving in home services?
Less than 1 year
1 - 5 years
5+ years
Clear selection
What services are you receiving from FIVCO?
Homemaking (housekeeping, shopping, laundry)
Personal Care
Home Delivered Meals
Respite
Are you receiving the services you need to maintain yourself in your home?
Yes
No
Clear selection
Do you know how to contact your case manager?
Yes
No
Clear selection
What is your Homemaker Aide's name?
Your answer
What day does the aide come to your home normally?
Monday
Tuesday
Wednesday
Thursday
Friday
Clear selection
How long does the aide stay in your home?
Your answer
Are you contacted in a timely manner if your schedule must be changed?
Yes
No
Clear selection
Do you receive any help from family, friends, or neighbors?
Yes
No
Clear selection
If you answered yes to the previous question, what type of help do they provide?
Your answer
Since you began receiving In-home services, is your condition:
Better
Worse
The Same
Clear selection
How would you rate FIVCO In-Home services?
Good
Fair
Poor
Clear selection
Do you feel like the services you are getting now are meeting your full needs?
Yes
No
Clear selection
What would happen if you could not get Homecare Services?
Your answer
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