SATISFACTION SURVEY
2015

Please answer all questions, adding any comments you'd like to make in the spaces provided.
The information on your report will be used to evaluate the quality of our 
services that your loved one receives. All responses will be kept confidential!

Please select services received

Please choose from the following list (check all that apply):
Residential/Family Care
Day Habilitation/OPTS
Medicaid Service Coordination
Transportation
Pallet Shop/Pre-Voc
Supported Employment
Family Support Services

Name of Individual Served (optional):

Please choose extremely satisfied, satisfied, somewhat satisfied, not satisfied, or I don't know to answer the questions below:

1. How satisfied are you with the Services provided by Saratoga Bridges?

Please choose from the following list: Extremely Satisfied Satisfied Somewhat Satisfied Not Satisfied Don't Know

Any comments about Question #1?

2. How satisfied are you with the responsiveness of the program staff to any issues/concerns you have raised.

Please choose from the following list: Extremely Satisfied Satisfied Somewhat Satisfied Not Satisfied Don't Know

Any comments about Question #2?

3. How satisfied are you with the management of this program?

Please choose from the following list: Extremely Satisfied Satisfied Somewhat Satisfied Not Satisfied Don't Know

Any comments about Question #3?

4. How satisfied are you with how the needs of  your loved one are being met?

Please choose from the following list: Extremely Satisfied Satisfied Somewhat Satisfied Not Satisfied Don't Know

Any comments about Question #4?

5. Please let us know if there are any employees of Saratoga Bridges that you would like to recognize for their good/outstanding work in service to your family member.

Names:

6. How satisfied are you with the overall quality of this program?

Please choose from the following list: Extremely Satisfied Satisfied Somewhat Satisfied Not Satisfied Don't Know

Any comments on Question #6?

Please give your answers to the following questions by filling in the box provided.

Program #1:   (Please type the name of the program your are reviewing) 

What do you like most about this program?

Are there any aspects of the program that need improvement?

Do you have any suggestions on ways to better communicate with families?:

Do you know whom to contact if you have a problem with this program? Yes No

Would you recommend this program/service to others? Yes No

Program #2:   (Please type the name of the program your are reviewing)

What do you like most about this program?

Are there any aspects of the program that need improvement?

Do you have any suggestions on ways to better communicate with families?:

Do you know whom to contact if you have a problem with this program? Yes  No

Would you recommend this program/service to others? Yes No

Program #3:   (Please type the name of the program your are reviewing)

What do you like most about this program?

Are there any aspects of the program that need improvement?

Do you have any suggestions on ways to better communicate with families?:

Do you know whom to contact if you have a problem with this program? Yes No

Would you recommend this program/service to others? Yes No

We would appreciate receiving your most current address, phone numbers, and email address:

Name:   

Day Phone #:   

Night Phone #:

Email:    

Address:

Valerie Muratori, Executive Director, vmuratori@saratogabridges.org or call at (518)587-0723

Dorothy Broekhuizen, Quality Assurance Coordinator, dbroekhuizen@saratogabridges.org or call at (518)587-0723

Please share any additional comments you may have, below: