Client Satisfaction Survey Form

Please read each question. At the end of that question, check the answer that you feel best describes the service you received from Victory Staffing & Home Care Services, Inc.

1. My aide/nurse is responsive to my needs

Strongly Agree

Agree

Disagree

Strongly Disagree

2. My aide/nurse listens when I talk.

Strongly Agree

Agree

Disagree

Strongly Disagree

3. My privacy/property is respected.

Strongly Agree

Agree

Disagree

Strongly Disagree

4. My aide/nurse makes their scheduled visits/shifts.

Strongly Agree

Agree

Disagree

Strongly Disagree

5. I am informed of any visit/shift changes.

Strongly Agree

Agree

Disagree

Strongly Disagree

6. I know how to contact the office if I have a problem or complaint.

Strongly Agree

Agree

Disagree

Strongly Disagree

7. When I call the office, the staff is courteous and helpful.

Strongly Agree

Agree

Disagree

Strongly Disagree

8. Overall, I am satisfied with the services provided by Victory Staffing & Home Care Services, Inc.

Strongly Agree

Agree

Disagree

Strongly Disagree

9. I would recommend Victory Staffing & Home Care Services, Inc to a family member or friend.

Strongly Agree

Agree

Disagree

Strongly Disagree

Comments/Suggestions for Improvement:

Who is your aide/nurse? (Please write their name here):

Patient Printed Name

Patient Signature

Date