Case Managers Satisfaction Survey

• Name:
• Your Location: City
• State -- Select A State -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Phone:

• In the past 6 months I have called upon HOMELINK:*

  1-10 times 11-20 times 21-40 times 41-60 times 61 + times

• I have called upon HOMELINK to coordinate: (please check all that apply)*

  • DME Equipment
  • Supplies i.e. wound or post-surgical
  • Nursing
  • Custom Mobility Equipment
  • Orthotics/Prosthetics
  • Sleep study evaluations and/or monitors
  • Medications/Pharmaceutical
  • Transportation
  • Other:

Please select the rating that best describes your experience with HOMELINK:

• Poor
• Average
• Fair
• Good
• Exceptional

1. 1) Staff were professional and knowledgeable

   • 1) Staff were professional and knowledgeable
   • Poor
   • Average
   • Fair
   • Good
   • Exceptional
2. 2) Staff followed-through as needed in a timely manner

   • 2) Staff followed-through as needed in a timely manner
   • Poor
   • Average
   • Fair
   • Good
   • Exceptional
3. 3) Timely forwarding of necessary documentation

   • 3) Timely forwarding of necessary documentation
   • Poor
   • Average
   • Fair
   • Good
   • Exceptional
4. 4) Staff were courteous

   • 4) Staff were courteous
   • Poor
   • Average
   • Fair
   • Good
   • Exceptional
5. 5) Communications are clear and concise

   • 5) Communications are clear and concise
   • Poor
   • Average
   • Fair
   • Good
   • Exceptional
6. 6) Trustworthy to follow-through as planned

   • 6) Trustworthy to follow-through as planned
   • Poor
   • Average
   • Fair
   • Good
   • Exceptional
7. 7) Providers chosen are reliable, professional and prompt

   • 7) Providers chosen are reliable, professional and prompt
   • Poor
   • Average
   • Fair
   • Good
   • Exceptional
8. 8) Patient care is number one priority

   • 8) Patient care is number one priority
   • Poor
   • Average
   • Fair
   • Good
   • Exceptional
9. 9) Fully attentive to your needs and requests

   • 9) Fully attentive to your needs and requests
   • Poor
   • Average
   • Fair
   • Good
   • Exceptional
10. 10) Complaints and/or concerns have been addressed in a timely manner

    • 10) Complaints and/or concerns have been addressed in a timely manner
    • Poor
    • Average
    • Fair
    • Good
    • Exceptional

• Other comments and/or suggestions:

Thank you for taking the time to let us know how we can improve our service. Your feedback is important to us!