Dear stakeholder,

Thank you for the opportunity to serve children and youths referred by your agency! Please answer the six
questions of our survey and fax the completed form to 404.761.0720, feel free to use additional pages for more
comments if needed. We appreciate your specific feedback and suggestions these comments will help us
improve our performance as an intensive in-home services provider as well as your community partner.

Thanks again and best regards,

Your JIREH team

STAKEHOLDERS’ SATISFACTION SURVEY

Date: _________________________

Respondent:____________________________ Agency/Organization: _______________________

1. How would you rate a quality of introduction to our services you received before you started using our
services (consider e.g., completeness and accuracy of informational session)
Low 1 2 3 4 5 High
Please explain. What we can do to improve our performance in this criterion?
_________________________________________________________________________________________
_________________________________________________________________________________________

2. How would you rate the quality of our services (consider e.g., good relationship with clients, addressing
appropriate problems with clients, linking them other resources)?
Low 1 2 3 4 5 High
Please explain. What we can do to improve our performance in this criterion?
_________________________________________________________________________________________
_________________________________________________________________________________________

3. How would you rate the professional behavior of our staff (e.g., staff integrity, competency, returning phone
calls within 24 hours, proper dress code, using the proper language)?
Low 1 2 3 4 5 High
Please explain. What we can do to improve our performance in this criterion?
_________________________________________________________________________________________
_________________________________________________________________________________________

4. How would you rate skills/knowledge/expertise of our clinical and administrative staff?
Low 1 2 3 4 5 High
Please explain. What we can do to improve our performance in this criterion?
_________________________________________________________________________________________
_________________________________________________________________________________________

5. How would you rate the quality and timeliness of our paperwork (please consider completeness, accuracy,
relevancy, on-time submission, reporting period)
Low 1 2 3 4 5 High
Please explain. What we can do to improve our performance in this criterion?
_________________________________________________________________________________________
_________________________________________________________________________________________

6. Are there any additional services that you would like to see us providing? If yes, which ones?
__________________________________________________________________________________
__________________________________________________________________________________

Fax to 404. 761. 0720

QI103-Stakeholder Satisfaction Survey Est. Mar 2008