Customer Service Survey

Best Home Health Care Agency in AR

Your Feedback is Important to Us

Thank you for taking the time to provide feed back on your experience with Subtle Whisper EC. Please fill out the form below . You may remain anonymous if you choose. If you would like to provide a testimonial, please add it in the area at the end of the form. Thanks You again for choosing us to care for you or your loved one.

Subtle Whisper Elite Care would appreciate your input in completing this Customer Service Survey as your feedback will help us to assess and improve the quality of the services that we provide to you. (Note: Your identification information may be withheld, if preferred.)

Name

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Date

Organization and Administration

Did you find us easy to contact?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Do you feel we responded in a timely manner?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Did We Give You Information on the following?

Brochure/other documentation about our servicesService Agreement  Rights & ResponsibilitiesContact details & numbers within normal office hoursName & number of the Agency Manager/designeeElder Abuse Hotline NumberEmergency numbersPlease tick the box next to the information you received.

Were you introduced to, or made aware of the Home Care Worker(s) assigned to you, prior to commencement of service?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Do you feel your needs/wants are being met & are being provided, in accordance with what was agreed upon? YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Service Delivery

Was a personal Service Plan developed & implemented?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Were you/your representative involved in developing the Service Plan?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Do you feel you are cared for in a respectful & nondiscriminatory way? YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

How many Home Care Workers are usually involved in your care?1 to 23 to 55 or morePlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Does your Home Care Worker(s) show up for work on time?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Does your Home Care Worker(s) stay for the specified time?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Does your Home Care Worker(s) provide all the care and services that we agreed to provide for you. YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Does a Supervisor regularly make a home visit?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Are you notified in advance if your Home Care Worker is going to be changed?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Is there anything that concerns you about your Home Care Worker(s)?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Were you advised who would be supervising your Home Care Worker(s)? YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Are you notified in advance if your regular services have to be rescheduled?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Were you advised who you/your representative/family may contact should you wish to speak to the Agency Manager or Supervisor ?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Were you advised that we may employ both male & female workers?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Were you asked if you prefer a male or female worker?YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Is your normal daily routine followed as much as possible within the provision of personal care such as getting up, meal times & bathing arrangements? YesNoPlease tick “Yes” or “No” for the following questions. If a “No” response is ticked, please elaborate on the reason(s) for the “No” rating in the “Comments” section at the end of the questionnaire.

Financial Matters

Do Home Care Workers shop and/or handle money for you?PoorFairGoodExcellent

If Home Care Worker(s) shop and/or handle money for you, do they always return the change and receipt(s)?YesNo

If Home Care Worker(s) return change and receipts to you, do you both sign the Financial Transactions Record?YesNo

Do Home Care Workers have you sign their Employee Time Sheet after each visit?YesNo

Evaluation

Do you feel we have the required knowledge & skills to deliver service?YesNo

Is there anything you don’t like about our service? YesNo

Have you any suggestions for ways we can improve our service?YesNo

Would you use our services in the future?YesNo

Would you recommend us to others?YesNo

How would you rate the overall quality of service you receive?ExcellentGoodFairPoor

How would you rate the Home Care Worker(s) treatment of you?ExcellentGoodFairPoor

How would you rate the amount of Supervision services being provided to you?ExcellentGoodFairPoor

How do you view the quality of service to its cost? ExcellentGoodFairPoor

Comments

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Best Home Health Care Agency in AR

Your Feedback is Important to Us