CONSUMER SATISFACTION SURVEY
Plain-text master, version 1.0.0. From ILDATA.org/instruments/consumer-satisfaction/

This file matches the online survey word for word. Answer values for keying a
paper response into the online record appear in square brackets after each
option, for example [rights]. Readers can ignore the brackets.

WHO SHOULD FILL THIS OUT
People who received services from a Center for Independent Living in the past 12 months. A family member or support person may help, but the answers should be the consumer's own.

BEFORE YOU START
- It takes about 7 minutes.
- You may skip any question except the first one.
- Your answers are confidential. The center sees counts and comments, never your name, unless you choose to give it at the end.
- Nothing you say here changes the services you receive.
- You can stop at any time. What you have answered so far still counts.

[ ] I understand, and I want to take part [consent=yes]
SECTION 1: THE SERVICES YOU RECEIVED

1.1 Which services did you receive from the center in the past 12 months? (Required)
   Check all that apply.
   [ ] Information and referral: Answers to a question, or being pointed to another program [info_referral]
   [ ] Independent living skills training: Learning to do things for yourself, like cooking, budgeting or using transit [il_skills]
   [ ] Peer support: Time with another person with a disability who has been there [peer_support]
   [ ] Help with my own advocacy: Help speaking up for yourself with a landlord, agency, school or employer [advocacy_individual]
   [ ] Systems advocacy: Working with the center to change a policy, law or practice [advocacy_systems]
   [ ] Moving out of a nursing home or institution: Or help staying out of one [transition_institution]
   [ ] Youth transition: Moving from school to adult life [transition_youth]
   [ ] Assistive technology [assistive_tech]
   [ ] Housing [housing]
   [ ] Employment [employment]
   [ ] Benefits: SSI, SSDI, Medicaid, food assistance and similar [benefits]
   [ ] Personal assistance services [personal_assistance]
   [ ] Transportation [transportation]
   [ ] Something else [other]
       Tell us what else you received: ______________________________ [cs_services_other_more]
   [ ] I am not sure [unsure]

1.2 How long have you been receiving services from the center?
   Choose one.
   ( ) Less than 3 months [lt_3m]
   ( ) 3 to 12 months [3_12m]
   ( ) 1 to 3 years [1_3y]
   ( ) More than 3 years [gt_3y]
   ( ) I am not sure [unsure]

1.3 How did you work with the center?
   Check all that apply.
   [ ] In person at the center [in_person_office]
   [ ] In person at my home or in my community [in_person_home]
   [ ] By phone [phone]
   [ ] By video call [video]
   [ ] By email or text [email_text]

SECTION 2: YOUR EXPERIENCE
For each statement, choose how much you agree. Choose "Does not apply" if a statement is not about something you experienced.

2.1 Staff treated me with respect.
   Choose one.
   ( ) Strongly agree [strongly_agree]
   ( ) Agree [agree]
   ( ) Neither agree nor disagree [neutral]
   ( ) Disagree [disagree]
   ( ) Strongly disagree [strongly_disagree]
   ( ) Does not apply [not_applicable]

2.2 Staff listened to what I wanted.
   Choose one.
   ( ) Strongly agree [strongly_agree]
   ( ) Agree [agree]
   ( ) Neither agree nor disagree [neutral]
   ( ) Disagree [disagree]
   ( ) Strongly disagree [strongly_disagree]
   ( ) Does not apply [not_applicable]

2.3 I set my own goals, and the center worked toward them.
   Choose one.
   ( ) Strongly agree [strongly_agree]
   ( ) Agree [agree]
   ( ) Neither agree nor disagree [neutral]
   ( ) Disagree [disagree]
   ( ) Strongly disagree [strongly_disagree]
   ( ) Does not apply [not_applicable]

2.4 I got information in a format I can use.
   For example large print, braille, plain language, my language, or a format my screen reader can read.
   Choose one.
   ( ) Strongly agree [strongly_agree]
   ( ) Agree [agree]
   ( ) Neither agree nor disagree [neutral]
   ( ) Disagree [disagree]
   ( ) Strongly disagree [strongly_disagree]
   ( ) Does not apply [not_applicable]

2.5 Help was available when I needed it.
   Choose one.
   ( ) Strongly agree [strongly_agree]
   ( ) Agree [agree]
   ( ) Neither agree nor disagree [neutral]
   ( ) Disagree [disagree]
   ( ) Strongly disagree [strongly_disagree]
   ( ) Does not apply [not_applicable]

2.6 The center's office, phone line and website were accessible to me.
   Choose one.
   ( ) Strongly agree [strongly_agree]
   ( ) Agree [agree]
   ( ) Neither agree nor disagree [neutral]
   ( ) Disagree [disagree]
   ( ) Strongly disagree [strongly_disagree]
   ( ) Does not apply [not_applicable]

2.7 I know how to reach the center if I need help again.
   Choose one.
   ( ) Strongly agree [strongly_agree]
   ( ) Agree [agree]
   ( ) Neither agree nor disagree [neutral]
   ( ) Disagree [disagree]
   ( ) Strongly disagree [strongly_disagree]
   ( ) Does not apply [not_applicable]

SECTION 3: WHAT CHANGED

3.1 Did the center's services help you reach what you wanted?
   Choose one.
   ( ) Yes, a lot [a_lot]
   ( ) Yes, somewhat [somewhat]
   ( ) Not yet: We are still working on it [not_yet]
   ( ) No [no]

3.2 What changed for you because of the center?
   Check all that apply.
   [ ] I do more for myself at home [more_independent]
   [ ] I take part in my community more [more_involved]
   [ ] I found or kept a place to live [housing]
   [ ] I found or kept a job, or started school or training [job]
   [ ] I got benefits or health coverage I did not have [benefits]
   [ ] I moved out of a nursing home or institution, or stayed out of one [left_facility]
   [ ] I learned a skill I use [skills]
   [ ] I know my rights and how to use them [rights]
   [ ] I have equipment or technology that helps me [tech]
   [ ] I feel less alone [connected]
   [ ] Something else [other]
       Tell us what else changed: ______________________________ [cs_changes_other_more]
   [ ] Nothing has changed yet [nothing]

3.3 Overall, how satisfied are you with the center?
   Choose one.
   ( ) Very satisfied [very_satisfied]
   ( ) Satisfied [satisfied]
   ( ) Neither satisfied nor dissatisfied [neutral]
   ( ) Dissatisfied [dissatisfied]
   ( ) Very dissatisfied [very_dissatisfied]

3.4 Would you recommend the center to another person with a disability?
   Choose one.
   ( ) Yes [yes]
   ( ) Maybe [maybe]
   ( ) No [no]

SECTION 4: IN YOUR OWN WORDS

4.1 Was there anything you needed that the center could not help with?
   ____________________________________________________________
   ____________________________________________________________ [cs_unmet]

4.2 What could the center do better?
   ____________________________________________________________
   ____________________________________________________________ [cs_improve]

4.3 Is there anything the center did especially well?
   ____________________________________________________________
   ____________________________________________________________ [cs_praise]

SECTION 5: ABOUT YOU (OPTIONAL)
These questions are optional. They help the center see whether it serves everyone in its area equally well.

5.1 Which county in your state do you live in?
   County: ______________________________ [cs_county = county FIPS code]
   ( ) I do not live in your state [outside]

5.2 What is your age?
   Choose one.
   ( ) Under 18 [under_18]
   ( ) 18 to 24 [18_24]
   ( ) 25 to 59 [25_59]
   ( ) 60 or older [60_plus]
   ( ) Prefer not to say [prefer_not]

5.3 Would you like someone from the center to contact you?
   Optional. Fill this in only if you want a call or an email about something you said here. Your contact details are stored separately from your answers.
   Name: ______________________________ [contact.name]
   Email: ______________________________ [contact.email]
   Phone: ______________________________ [contact.phone]

THANK YOU
Your answers have been recorded. the organization running this survey reviews consumer satisfaction results to improve services and reports them, as counts, to the Statewide Independent Living Council.

Question identifiers are stable across versions of this instrument so results
pool across organizations and years. See ILDATA.org/standards/question-bank/