Word-Import - 1

Columbia Lighthouse for the Blind

Client 3 and 6 month Satisfaction Survey

CLB is asking for your cooperation in completing and returning the following anonymous survey. In order for us to improve our programs and better understand those we serve, this survey has been developed to provide information in a variety of topic areas. This survey can be completed over the phone with a volunteer if necessary.

Age: ______________________________________

Eye Condition: ______________________________

Please check all services in which you have participated:

____ Foundations and Adjustment to Blindness Training Program

Month: _______________ Year: ________

____ In-home training

Instructor(s):________________________

____ Support group

____ Circle of Friends activities

____ One-time workshop, activity, or other event

____ Other

Please list: __________________________

Please use the following scale when answering questions

A. Never

B. Sometimes

C. Always

D. Want to learn

1. I use a white cane for travel.

2. Do you feel that you have made functional gains in safety and independence after your mobility training?

3. I read Braille or use it for organization or labeling.

5. I am able to cook for myself.

6. Do you feel more comfortable and safer in the kitchen than before the training?

7. I use assistive technology to improve the quality of my daily life

8. I use a computer with adaptive software program to complete daily tasks.

9. If you used a computer before CLB’s training, will the software or techniques that you have learned help you with your continued use?

10. I shop independently for groceries and personal items using the store’s customer service employees.

12. Did you find useful information from the resource packets that were provided after the Foundations and Adjustment to Blindness Training, workshop, support group, seminar, or in-home visit?

1.Do you feel that you are in greater control, with more confidence in yourself to maintain your current living situation as a result of the training and services that you have received?

15. Would you find additional training in the areas that were taught at the Foundations and Adjustment to Blindness Training, training workshop, support group, seminar, or in-home visit important to your continued growth and independence? E.G. Orientation and Mobility, Independent living skills, computers, Braille, support groups, adjustment to blindness seminars

16. Are you receiving any training currently?

17. Would you recommend our program to others?

2.Do you belong to any consumer groups or vision loss/low vision support groups?

19. Do you have any other comments?________________________________________________________________________________________________________________________________________________________________________

Thank you for your participation!