COBRA - COMMUNITY FOLLOW-UP PROGRAM CONSUMER SURVEY
? Gender Male Female Transgender
? Racial/ethnic background White (non-Hispanic) Black/African American Hispanic
Asian / Pacific Islander Native American Other ? Age 0-19 20-29 30-39 40-49 50 +
_________ ? Number in household
_________ ? Number of children (under
_________ ? Zip code of residence
1. How long have you been a client of the COBRA Community Follow-up Program?
Less than 6 months 6 months to 1 year 1 to 2 years 2 years or more
2. Do you understand what COBRA Community Follow-up Program case management services are?
Completely Mostly Somewhat Not at all
3. As a COBRA Community Follow-up Program client, do you understand your right to: Yes No Unsure
? have your information kept confidential?
? participate in planning services with the ability to refuse services?
? file a complaint?
All of Most of Some of Never
the time the time the time
4. Do you believe that your HIV and medical information is kept confidential by your case
5. Does your case manager/team listen to what you say?
6. Does your case manager/team help you understand information about current or other available
7. Does your case manager/team help you to get services to deal with your needs and problems?
8. Does the COBRA Community Follow-up Program staff treat you and your family with respect
9. Does your case manager/team encourage you to make your own choices about your services?
10. Does your case manager/team help you to make and keep appointments for your other services?
11. Does your case manager/team help you when you are having difficulty getting other services?
12. a. How often do you see your case manager/team? (circle one)
less than once/month ____ ; 1/month ____ ; 2/month ____; 3 times/month or more ____
b. Are case management services available on days and times which are convenient for you? Yes No
If no, please explain: ______________________________________________________________________________________________
13. What do you like most about the COBRA Community Follow-up Program? ________________________________________________
14. Would you recommend COBRA Community Follow-up Program case management services to a friend or someone else you know?
Yes No Explain: ________________________________________________________________________________________
15. What could the COBRA Community Follow-up Program do to improve its services to clients? (such as offer child care, lengthen office hours, improve office conditions) : _______________________________________________________________________________
OPTIONAL: More Less No Unsure or
Often Often Change Does not apply Since you have been receiving services from the Community Follow-
up Program, do you:
? Keep your medical appointments
? Take medications as prescribed
? Use Mental Health services as recommended
? Get better care from other agencies
? Get services you need on your own
? Keep your drug/alcohol program appointments
? Take better care of yourself
? Feel better able to care for your children
? Manage crisis situations
? Practice safer sex
? Practice harm reduction in drug use (for example, using a new
sterile needle with each injection, not sharing needles, reducing or
eliminating overall drug use, changing from injection to snorting)
? Feel better about yourself
? Feel Empowered
Since you have been receiving services from the Community Follow-up Yes No No Unsure or Does Program, do you: Change Not Apply
? Understand your medical treatment
? Need to use emergency rooms less frequently
? Know where you can go to get the services you need
? Understand legal issues (example, health care proxy)
Since you have been receiving services from the COBRA Community Yes No No Unsure or Does Follow-up Program, have you: Change Not Apply
? Begun to make plans for your children’s future
? Secured better housing
? Improved your education or job training skills
? Sought or secured employment
? Gained better financial resources( ex. SSI, food stamps, medical
Rev. 2/5/99 consurv6