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Sample Revised Survey (Hard Copy) D~VIS STREET FAMILY RESOURCE CENTER hel1~ing others liel~i th~rnselves Please take a few minutes to help us understand how we can better serve your needs! Editorial Note: This survey form assumes that the demographic portion can be automatically included from the intake system. If that is the case, and if the responses to this survey are entered into the computer for storage and analysis, then there is no real reason to include it on the survey form. However, I've included it for cases where hard copy versions are the only versions being analyzed. Enclosed borders indicate the demographic portion that would be automatically printed from the intake system. From our intake interview with you today, we understand that: The Service(s) you are hereto receive include: [auto input service #1] [auto input service #2] The individuals in your group that are using our services today include: [auto input from intake which, for each person, indicates age, ethnicity, race, educational level] We show your current total household income per month to be: [auto input from intake) We show your zip code as : [auto input from intake] You first came to DSFRC: [input date from intake system] Our records show that in the past, you or your family has used these Davis Street services: [list from intake] Our records show that you first learned of Davis Street from: [input from intake] Our records show that you used [input from intake] as your form of tran How easy was it for you or your family to access toda 's services/programs? ^ Very easy ^ Somewhat easy ^ Not very easy ^ Very difficult How can we make DSFRC more accessible to you? What other services are you or your family needing and are unable to access in the community? ^Transportation ^Housing ^Education ^LegalAid ^Shelter ^AdultDental ^Child Dental ^Other (please explain) Sustainability Study: Davis Street Family Resource Center -4/08 Page 79 of 96