CONSUMER SATISFACTION SURVEY (Individual Format) Project Activity: _______________________________________________________________ We want to know what you think about this project activity by asking the following questions: Directions Please check the category that best describes you. – Individual with a disability Family member other________________ Directions- Yes No Please circle either or to tell us your opinion about the following statements. I was treated with respect during this project activity. Yes No (or my family member) I have more choice and control as a (or my family member) result of this project activity. Yes No I can do more things in my community as a result (or my family member) of this project activity. Yes No Directions- Please circle the number that best describes your opinion. I am satisfied with this project activity. 4 3 2 1 Strongly Agree Disagree Strongly Agree Disagree My life is better because of this project activity. 4 3 2 1 Strongly Disagree Strongly Agree Disagree What has been helpful or not helpful about this project activity? Questions 6 & 7 (These are optional questions to be used when a project activity includes rights and protection issues.) 6. Because of this project activity, I Yes No (or my family member) know my rights. 7. I am more able to be safe and (or my family member) protect myself from harm as a result of this project activity. Yes No
CONSUMER SATISFACTION SURVEY (Individual Format) Project Activity: _______________________________________________________________ We want to know what you think about this project activity by asking the following questions: Directions – Please check the category that best describes you. Individual with a disability Family member other________________ Directions- Please circle either Yes or No to tell us your opinion about the following statements. I (or my family member) was treated with respect during this project activity. Yes No I (or my family member) have more choice and control as a result of this project activity. Yes No I (or my family member) can do more things in my community as a result of this project activity. Yes No Directions- Please circle the number that best describes your opinion. I am satisfied with this project activity. 4 3 2 1 Strongly Agree Disagree Strongly Agree Disagree My life is better because of this project activity. 4 3 2 1 Strongly Disagree Strongly Agree Disagree What has been helpful or not helpful about this project activity? Questions 6 & 7 (These are optional questions to be used when a project activity includes rights and protection issues.) 6. Because of this project activity, I (or my family member) Yes No know my rights. 7. I (or my family member) am more able to be safe and protect myself from harm as a result of this project activity. Yes No
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