TN SIS® SATISFACTION SURVEY

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* We would appreciate feedback about your SIS® assessment experience.

Your Name *

Name of Person Assessed in the SIS

Relationship to the Individual

Assessment Date *

Your Phone

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* Assessor Name:

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* Did the assessor arrive on time?

Yes

No

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* Did you receive a reminder call about the meeting time?

Yes

No

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* Length of Assessment:

Less than 1 hour

1 to 2 hours

2 to 3 hours

More than 3 hours

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* Rate your agreement with the following statements:

	Disagree	Somewhat Disagree	Neutral	Somewhat Agree	Agree
The assessment was scheduled at a time, date, and location that worked well for me.	The assessment was scheduled at a time, date, and location that worked well for me. Disagree	The assessment was scheduled at a time, date, and location that worked well for me. Somewhat Disagree	The assessment was scheduled at a time, date, and location that worked well for me. Neutral	The assessment was scheduled at a time, date, and location that worked well for me. Somewhat Agree	The assessment was scheduled at a time, date, and location that worked well for me. Agree
The scheduler was polite and spoke clearly.	The scheduler was polite and spoke clearly. Disagree	The scheduler was polite and spoke clearly. Somewhat Disagree	The scheduler was polite and spoke clearly. Neutral	The scheduler was polite and spoke clearly. Somewhat Agree	The scheduler was polite and spoke clearly. Agree
The person’s support team was well represented at the assessment.	The person’s support team was well represented at the assessment. Disagree	The person’s support team was well represented at the assessment. Somewhat Disagree	The person’s support team was well represented at the assessment. Neutral	The person’s support team was well represented at the assessment. Somewhat Agree	The person’s support team was well represented at the assessment. Agree
The assessor was polite and spoke clearly.	The assessor was polite and spoke clearly. Disagree	The assessor was polite and spoke clearly. Somewhat Disagree	The assessor was polite and spoke clearly. Neutral	The assessor was polite and spoke clearly. Somewhat Agree	The assessor was polite and spoke clearly. Agree
The assessor treated me/us with dignity and respect.	The assessor treated me/us with dignity and respect. Disagree	The assessor treated me/us with dignity and respect. Somewhat Disagree	The assessor treated me/us with dignity and respect. Neutral	The assessor treated me/us with dignity and respect. Somewhat Agree	The assessor treated me/us with dignity and respect. Agree
The assessor took the time to learn about the person’s support needs.	The assessor took the time to learn about the person’s support needs. Disagree	The assessor took the time to learn about the person’s support needs. Somewhat Disagree	The assessor took the time to learn about the person’s support needs. Neutral	The assessor took the time to learn about the person’s support needs. Somewhat Agree	The assessor took the time to learn about the person’s support needs. Agree
The assessment effectively captured the person’s support needs.	The assessment effectively captured the person’s support needs. Disagree	The assessment effectively captured the person’s support needs. Somewhat Disagree	The assessment effectively captured the person’s support needs. Neutral	The assessment effectively captured the person’s support needs. Somewhat Agree	The assessment effectively captured the person’s support needs. Agree

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* Do you have any other feedback about the assessment tool (feedback to the state), the assessor, the scheduling process, or anything else?