Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Date. Enter the numbers representing today’s date (the date on which the client completes the survey) in these boxes. Enter the month as a number from 01 to 12 corresponding to January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "96" for 1996). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure that each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the staff who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

How will this questionnaire be completed? Darken the circle next to "Self-Administered," if the client fills out the questionnaire him/herself; darken the circle next to "Self-Administered with help," if you help the client fill out the questionnaire; darken the circle next to "Face-to-face interview," if you fill out the questionnaire for the client in person; darken the circle next to "Phone interview," if you fill out the questionnaire for the client during a phone interview with him or her.

For Modules that are to be Self-Administered by the Client

If the Module is to be self-administered by the client, read the following instructions (indicated by italics) exactly as they are written below to the client. Begin the instructions by stating the name of your program/project:

(Name Of Your Program/Project) would like to know what works about this program, what doesn’t work at all, and how we can provide better services for you and others like you. Would you help us to do this by completing a client satisfaction questionnaire? The questionnaire is very short and will probably not take you more than a few minutes to complete.

 

We are working with an independent company who will look at the questionnaire. We will not see anything you write on the questionnaire form. Please do not write your name anywhere on the form, as the survey is to be completely anonymous--that is, nobody will know that you were the one giving the particular answers. It is also, completely confidential--that is, I nor anyone from (Name Of Your Program/Project), will see any of your answers.

 

If you would like to complete the questionnaire, I will give you a pre-addressed and postage-paid envelope that you can use to send the questionnaire directly to the independent company who is helping us. When you have finished the questionnaire, you can either drop it in the box here or in any regular U.S. mail box.

 

Even if you don’t want to complete the questionnaire, I would still like to thank you for your time. Would you like to take the time now to complete the questionnaire?

 

If, after you have read aloud to the client the instructions above, the client agrees to complete the module, give him/her the module, a pre-addressed postage-paid envelope, and a black pen.

For Modules that are to be Self-Administered by the Client with Help or that are Administered as a Face-to-Face or Phone Interview

If desired, the Module can be administered as a face-to-face or phone interview. If the Module is to be administered by you as a face-to-face or phone interview, read the following instructions (indicated by italics) exactly as they are written below to the client. These instructions can also be used for clients who self-administer the module with project staff help. Begin the instructions by stating the name of your program/project:

(Name Of Your Program/Project) would like to know what works about this program, what doesn’t work at all, and how we can provide better services for you and others like you. Would you help us to do this by completing a client satisfaction questionnaire? The questionnaire is very short and will probably not take us more than a few minutes to complete.

 

We are working with an independent company who will look at the questionnaire. Nobody else at (Name Of Your Program/Project) will see anything that is written on the questionnaire form. I will not write your name anywhere on the form. In this respect, the survey will be completely anonymous to others--that is, nobody else will know that you were the one giving the particular answers. It is also, completely confidential--that is, no one from (Name Of Your Program/Project) will see any of your answers.

 

If you do not know the answer to a question or if you choose not to answer it, you can tell me. We can stop filling in the questionnaire at any time.

 

As soon as we are through, I will mail the questionnaire in this envelope to the independent company (if this is a face-to-face format, project staff should show the envelope at this time).

 

Even if you don’t want to complete the questionnaire, I would still like to thank you for your time. Would you like to take the time now to complete the questionnaire?

 

If the client agrees to complete the module after you have read the instructions above, using a black pen, begin to complete the module. After completing the module, make sure that the client sees you seal it in the envelope provided.

The Interview Portion For the Self-Administered- With-Help and Face-to-Face Administration Begins Here

Start this portion by completing the section labeled, "CLIENT: Would you please provide the following information?:"

Your Gender: Darken the circle next to the response that indicates the person’s gender.

Your Age: Ask the client:

What is your age?

 

Write in the client’s response in the boxes provided.

Read to the client the following:

For the remaining questions, I am going to hold up a response card. I would like you to go over the options you have to answer each question and then choose one. What is your primary ethnic/cultural/racial background?

 

Show the client Response Card A, and slowly read the choices written there. Darken the bubble next to the selection corresponding to the client’s response.

1. Read to the client the following:

Now, we’d like to know what your opinions are about the staff and services here. I am going to read you a statement. Please look over the response card I am going to show you, and select the letter that corresponds to the response that best describes your opinion about that statement.

 

Overall, I think the services here are:

 

For Item 1, show the client Response Card B and darken the bubble corresponding to the letter indicating the client’s response.

2. Read to the client the following:

The information that I have received here has been:

 

For Item 2, show the client Response Card C and darken the bubble corresponding to the letter indicating the client’s response.

3. Read to the client the following:

The staff here answer my questions:

 

For Item 3, show the client Response Card D darken the bubble corresponding to the letter indicating the client’s response.

4. Read to the client the following:

The staff here tell me in advance about treatment procedures that I should have:

 

For Item 4, show the client Response Card D and darken the bubble corresponding to the letter indicating the client’s response.

5. Read to the client the following:

The staff here treat me like an individual with unique needs and concerns:

 

For Item 5, show the client Response Card D and darken the bubble corresponding to the letter indicating the client’s response.

6. Read to the client the following:

The staff here respect my privacy:

 

For Item 6, show the client Response Card D and darken the bubble corresponding to the letter indicating the client’s response.

7. Read to the client the following:

The staff here are available to help me when I have questions:

 

For Item 7, show the client Response Card D and darken the bubble corresponding to the letter indicating the client’s response.

8. Read to the client the following:

Would you tell you tell your friends that they should come here if they have needs like yours?:

 

For Item 8, show the client Response Card E and darken the bubble corresponding to the letter indicating the client’s response.

Note: The following questions (items 9 through 12) are to be directed to clients having particular characteristics.

9. Read the following only if the client is 24 years of age or younger:

The staff here understand the treatment needs of young people:

 

For Item 9, show the client Response Card D. and darken the bubble corresponding to the letter indicating the client’s response.

10. Read the following only if the client is 55 years of age or older:

The staff here understand the treatment needs of older adults:

 

For Item 10, show the client Response Card D. and darken the bubble corresponding to the letter indicating the client’s response.

11. Read the following only if the client is a person of color:

The staff here understand the treatment needs of people of my ethnic/cultural group:

 

For Item 11, show the client Response Card D and darken the bubble corresponding to the letter indicating the client’s response.

12. Read the following only if the client is female:

The staff here understand the treatment needs of women:

 

For Item 12, show the client Response Card D and darken the bubble corresponding to the letter indicating the client’s response.

13. Read the following to ALL clients:

I’d like to ask you one last question. There’s no Response Card for this. If we were going to make changes to improve services for you, or people like you, what changes would you like to see us make?

 

Listen to the client’s response and print a summary in the space provided for Item 13 on Page 2 of Module 11.

Module 11

Card A

White (including Caucasian, Middle Eastern, North African) but not Hispanic

 

African-American/Black (but not Hispanic)

 

Hispanic/Latino

 

Asian/Pacific Islander

Native American, Aleutian, Alaskan or Eskimo

Module 11

Card B

a. Excellent

b. Very

c. Good

d. Good

e. Fair

f. Poor

Module 11

Card C

a.Very Helpful

b. Helpful

c. Not Very

d. Helpful

e. Not At All Helpful

Module 11

Card D

a. All of the Time

b. Most Times

c. Sometimes

d. Rarely or Never

Module 11

Card E

a. Definitely Yes

b. Probably

c. Probably not

d. Definitely not

Module 11

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