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Employment Client Satisfaction
To complete the form below, all questions must be answered, except as noted.
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Client Information
First Name
*
Last Name
*
Email Address
*
Case Manager Information
First Name
Last Name
Email Address
*
Community Skills Trainer Information
First Name
Last Name
Email Address
1. What are your goals that you are currently working on?
2. Does your Job Coach/Community Skills Trainer assist you in meeting goals/objectives?
*
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
3. Do you feel that you have made progress in your goals?
*
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
4. Does your Job Coach/Community Skills Trainer listen to your work related concerns?
*
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
5. Do you feel the LTC staff provides you with the support you need?
*
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
6. Do you feel that you have been informed of the choices you can make?
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
7. Do you feel that you are an active participant in the development of your plan?
*
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
8. Do you feel that you are treated well and with respect?
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
9. Can you find your Job Coach when you need him/her?
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
10. Do you feel that you are a part of the company?
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
11. Do you feel that you are prepared to become/stay successfully employed?
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
12. Are you happy with your current job?
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
13. What part of your job do you like?
14. What part of your job do you not like?
15. Is there another type of job that you are interested in?
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
16. Do you think it is a safe and clean environment where you work?
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
17. Would you recommend this service to a friend?
Always
Most of the Time
Some of the Time
Not Enough of the Time
Comments (optional)
18. What can we improve to serve you better?
19. Any additional concerns/comments?
To the Interviewer
A. Do you think the client understood the questions asked?
Yes
No
Some
B. Is the client?
Verbal
Non-verbal
Comments (optional)
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