If you would like help completing this survey,

please call 1-800-643-6457 and ask for Dorothy.

PART I

Please check the box that describes your feelings about the services you received.

1.  Which IL Center or program did you receive services from? WILR WSIL BIAW

2.  Could the IL Center or program better serve your needs? Yes No N/A   Comments:

3.  Is the IL Center or program easy to get to or to get inside? Yes No N/A   Comments:

4.  What could make the IL Center or program more accessible to your needs?

5.  Would you recommend your IL Center or program to a friend with a disability? Yes No N/A

Why or why not?

6.  Did you request services that could not be provided by the IL Center or program? Yes No N/A

Please describe:

7.  Did you understand your rights as a client ?  Yes No N/A  

8. Please select the services that you received, and provide descriptions of those services, where indicated.

I was given information and help regarding ways to live more independently.  

I was referred to another agency. 

I was given assistance with daily living.  (Examples: housekeeping, cooking, money management, other)

I learned daily living skills. (Examples: housekeeping, cooking, money management, other)

I received personal care services.  (Examples: bathing, dressing)

I received recreation services.  (Examples: swimming, recreation center, other)

I received Senior Companion services.

I received transportation services.  (Examples: CATC tickets, ride vouchers, other)

I received assistance to obtain benefits.  (Examples: food stamps, SSA, SSI, Voc. Rehab., etc.)

I received equipment or other items I needed.  (Examples: wheelchair, low-vision equipment)

Part II

1. It was easy to get an appointment with my IL Specialist.

Yes No N/A

2. The staff is/was good to me.

Yes No N/A

3. I get to choose my goals and the assistance I need to meet my goals.

Yes No N/A

4. The services I get are useful and have helped me to live on my own.

Yes No N/A

5. I understand the information given to me and I know how I can help myself.

Yes No N/A

6. I am satisfied with the services I am/was receiving.

Yes No N/A

7. Please provide any comments you would like to make regarding services, staff, programs, problems or something you think we did well.

If you would like someone to contact you, please include your name, address, phone number, and/or e-mail address.  All contacts will be kept confidential unless otherwise requested.