Respite Coordinator Satisfaction Survey

Respite Coordinator Name

Please check a box for each question below:

Questions	Never/Not at all	Rarely	Neutral	Sometimes	Always
Is available during posted office hours	Never/Not at all	Rarely	Neutral	Sometimes	Always
Returns calls and emails in a timely manner	Never/Not at all	Rarely	Neutral	Sometimes	Always
Is responsive to my questions and needs	Never/Not at all	Rarely	Neutral	Sometimes	Always

Define/give examples

Please check a box for each question below:

Questions	Never/Not at all	Rarely	Neutral	Sometimes	Always
Hosts respite events and activities that are of interest to me and my family/loved ones	Never/Not at all	Rarely	Neutral	Sometimes	Always
Is in contact with me regularly	Never/Not at all	Rarely	Neutral	Sometimes	Always

My coordinator contacts me at least 1 time per month

Yes

No

Please check a box for each question below:

Questions	Never/Not at all	Rarely	Neutral	Sometimes	Always
Assists me in locating respite provider(s) in my area	Never/Not at all	Rarely	Neutral	Sometimes	Always
Assists me with finding resources to better the quality of life for myself and my loved one(s)	Never/Not at all	Rarely	Neutral	Sometimes	Always
Seems knowledgeable of the Respite Subsidy and program benefits and/or processes	Never/Not at all	Rarely	Neutral	Sometimes	Always