Deaf Services Center

Please print this form first and then complete it.

Community Resources Satisfaction Survey

Deaf Service Center, Inc.
Interpreting & Community Resources
5830 North High Street
Worthington, OH 43085-3959

Deaf Services Center is pleased to have provided you with case management and/or community advocacy services. Please take a few minutes to answer this survey below and give it back to us quickly. Your feedback helps us improve our services we provide to you. Thank you.

Name or Company: __________________________________ Today's Date: ______________
(Optional)

Date of last appointment/contact with staff: ____________________________________________

PLEASE CIRCLE ONE

Did you have an appointment or just show up?

Appointment Show up

Did the staff member see you right away?

Yes No

Did the staff member dress and act professional to you?

Yes No

Did you understand the communication with the staff person clearly?

Yes No

Did the staff member keep communication private?

Yes No

If no, why? ______________________________________________________________________

_______________________________________________________________________________

How can DSC staff or services improve? ______________________________________

______________________________________________________________________

Who sends/refers you to DSC?   (please check)
____     Professional referral (i.e. doctor, counselor, BVR, school, lawyer, etc.)
____     Family and/or Friend
____     Advertisement (i.e. brochure, DSC booth, flier, newspaper, etc.)
____     Other (please explain: ____________________________________________________ )

Thank you for taking the time to fill out this survey. You may put this in our "Client Satisfaction Survey" box at our main office OR fax it to us at (614) 841-4909 OR mail it to us at: Community Resources Director, Deaf Services Center, Inc. 5830 North High Street, Worthington OH 43085.