DOC

Comminity Follow-up Program

By Samantha Wells,2014-01-10 20:25
7 views 0
Comminity Follow-up Program

    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

    18)

    _________ ? 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

    manager/ team?

     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

    services?

     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

    and dignity?

     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

     coverage)

Rev. 2/5/99 consurv6

Report this document

For any questions or suggestions please email
cust-service@docsford.com