"Empowering people with disabilities to live independently in our community."

CUSTOMER QUESTIONNAIRE REGARDING PERSONAL ASSISTANT SERVICES

Consumer's Name
Date
Have you hired a personal assistant within the past three months?
Is that personal assistant still employed by you?
Personal assistant's name
Have you hired more than one PA?
If so, please supply the names if possible
Please select the statement that best describes your current level of satisfaction in the working relationship between you and your current Personal Assistant.
Accuracy of Work
Follows instructions completely and works well unsupervised.
Usually follows instructions and works with minimal supervision.
Does not follow instructions and needs constant supervision.
Attendance
Never late or absent.
Occasionally late/absent, but calls to let me know.
Often late or absent, which interferes with tasks being completed.
Environment
Exceptionally clean/orderly.
Sometimes forgets assigned tasks.
Often cleaning is not done.
Attitude
Is very easy to work with and seldom has a bad day.
Occasionally has an attitude problem, which interferes.
I am sometimes afraid of/for my safety/care due to irresponsible actions and/or attitude.
Job Knowledge/Responsibilities
Understands job requirements.
Does not always do the job as instructed by me.
Totally disregards my instructions and schedule.
Overall satisfaction with personal assistant (5 being best)
Comments
Would you like to nominate your personal assistant for the Personal Assistant Award?
With regard to the PA Program overall, have you been satisfied with the service you have received?

©2007 Advocates for Access. All rights reserved.
4450 N. Prospect Road, Suite C8, Peoria Heights, IL 61616
v/vp: 309.682.3500 :: tty: 309.682.3567 :: f: 309.682.3989 :: e: info@advocatesforaccess.com
Site design by Ted Stephens III Web Design.