Instructions: Module 11 Capitated Care - TheMeasurementGroup.com

SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 11: CLIENT SATISFACTION SURVEY -

CAPITATED CARE PROJECTS INSTRUCTIONS

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the sides of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks for the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Specific Parts of the Module 11: Client Satisfaction Survey -

Capitated Care Projects

Note: Module 11 Client Satisfaction Survey - Capitated Care Projects consists of one page. Project staff should complete the section which is shaded in gray and which is labeled: "Shaded area is FOR OFFICE USE ONLY." Project staff should complete this information before administering the remainder of the module. The remainder of the module may be administered as a face-to-face interview or phone interview, or given to the client to fill out either with or without project staff help.

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. If you prefer the client to complete Module 11 anonymously, leave the ID Letters and ID Numbers boxes blank. If not, follow these instructions: The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Date. Enter the numbers representing today’s date (the date on which the client completes the survey) in these boxes. Enter the month as a number from 01 to 12 corresponding to January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "96" for 1996). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure that each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the staff who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003." Each staff member should be assigned a unique number code (up to 3 digits). Make sure that each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the staff who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

How will this questionnaire be completed? Darken the circle next to "Self-Administered," if the client fills out the questionnaire him/herself; darken the circle next to "Self-Administered with help," if you help the client fill out the questionnaire; darken the circle next to "Face-to-face interview," if you fill out the questionnaire for the client in person; darken the circle next to "Phone interview," if you fill out the questionnaire for the client during a phone interview with him or her. Darken the circle next to "Self-Administered," if the client fills out the questionnaire him/herself; darken the circle next to "Self-Administered with help," if you help the client fill out the questionnaire; darken the circle next to "Face-to-face interview," if you fill out the questionnaire for the client in person; darken the circle next to "Phone interview," if you fill out the questionnaire for the client during a phone interview with him or her.

For Modules that are to be Self-Administered by the Client

If the Module is to be self-administered by the client, read the following instructions (indicated by italics) exactly as they are written below to the client. Begin the instructions by stating the name of your program/project:

(Name Of Your Program/Project) would like to know what works about this program, what doesn’t work at all, and how we can provide better services for you and others like you. Would you help us to do this by completing a client satisfaction questionnaire? The questionnaire is very short and will probably not take you more than a few minutes to complete.

We are working with an independent company who will look at the questionnaire. We will not see anything you write on the questionnaire form. Please do not write your name anywhere on the form, as the survey is to be completely anonymous--that is, nobody will know that you were the one giving the particular answers. It is also, completely confidential--that is, I nor anyone from (Name Of Your Program/Project), will see any of your answers.

If you would like to complete the questionnaire, I will give you a pre-addressed and postage-paid envelope that you can use to send the questionnaire directly to the independent company who is helping us. When you have finished the questionnaire, you can either drop it in the box here or in any regular U.S. mail box.

Even if you don’t want to complete the questionnaire, I would still like to thank you for your time. Would you like to take the time now to complete the questionnaire?

If, after you have read aloud to the client the instructions above, the client agrees to complete the module, give him/her the module, a pre-addressed postage-paid envelope, and a black pen.

For Modules that are to be Self-Administered by the Client with Help or that are Administered as a Face-to-Face or Phone Interview

If desired, the Module can be administered as a face-to-face or phone interview. If the Module is to be administered by you as a face-to-face or phone interview, read the following instructions (indicated by italics) exactly as they are written below to the client. These instructions can also be used for clients who self-administer the module with project staff help. Begin the instructions by stating the name of your program/project:

(Name Of Your Program/Project) would like to know what works about this program, what doesn’t work at all, and how we can provide better services for you and others like you. Would you help us to do this by completing a client satisfaction questionnaire? The questionnaire is very short and will probably not take us more than a few minutes to complete.

We are working with an independent company who will look at the questionnaire. Nobody else at (Name Of Your Program/Project) will see anything that is written on the questionnaire form. I will not write your name anywhere on the form. In this respect, the survey will be completely anonymous to others--that is, nobody else will know that you were the one giving the particular answers. It is also, completely confidential--that is, no one from (Name Of Your Program/Project) will see any of your answers.

If you do not know the answer to a question or if you choose not to answer it, you can tell me. We can stop filling in the questionnaire at any time.

As soon as we are through, I will mail the questionnaire in this envelope to the independent company (if this is a face-to-face format, project staff should show the envelope at this time).

Even if you don’t want to complete the questionnaire, I would still like to thank you for your time. Would you like to take the time now to complete the questionnaire?

If the client agrees to complete the module after you have read the instructions above, using a black pen, begin to complete the module. After completing the module, make sure that the client sees you seal it in the envelope provided.

The Interview Portion For the Self-Administered- With-Help and Face-to-Face Administration Begins Here

Start this portion by completing the section labeled, "CLIENT: Would you please provide the following information?:"

Your Gender: Darken the circle next to the response that indicates the person’s gender.

Your Age: Ask the client: Ask the client:

What is your age?

Write in the client’s response in the boxes provided.

Read to the client the following:

For the remaining questions, I am going to hold up a response card. I would like you to go over the options you have to answer each question and then choose one. What is your primary ethnic/cultural/racial background?

Show the client Response Card A, and slowly read the choices written there. Darken the bubble next to the selection corresponding to the client’s response.

1. Read to the client the following:

Now, we’d like to know what your opinions are about the staff and services here. I am going to read you a statement. Please look over the response card I am going to show you, and select the letter that corresponds to the response that best describes your opinion about that statement.

Overall, I think the services here are:

For Item 1, show the client Response Card B and darken the bubble indicating the client’s response.

2. Read to the client the following:

The information that I have received here has been:

For Item 2, show the client Response Card C and darken the bubble indicating the client’s response.

3. Read to the client the following:

I have asked the staff here for information that I have not received:

For Item 3, show the client Response Card D darken the bubble indicating the client’s response.

4. Read to the client the following:

The information that I have received from the staff has generally been:

For Item 4, show the client Response Card F and darken the bubble indicating the client’s response.

5. Read to the client the following:

The staff here answer my questions:

For Item 5, show the client Response Card D and darken the bubble indicating the client’s response.

6. Read to the client the following:

The staff here provide information about my illness:

For Item 6, show the client Response Card D and darken the bubble indicating the client’s response.

7. Read to the client the following:

The staff here treat me like I am an individual with unique needs and concerns:

For Item 7, show the client Response Card D and darken the bubble indicating the client’s response.

8. Read to the client the following:

The staff here keep information about me private:

For Item 8, show the client Response Card D and darken the bubble indicating the client’s response.

9. Read to the client the following:

The staff here are available to me when I need them:

For Item 9, show the client Response Card D. and darken the bubble indicating the client’s response.

10. Read to the client the following:

Services here are available to me when I need them:

For Item 10, show the client Response Card D. and darken the bubble indicating the client’s response.

11. Read to the client the following:

Would you go somewhere else to get services, if you could?:

For Item 11, show the client Response Card E and darken the bubble corresponding to the letter indicating the client’s response.

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Card A

White (including Caucasian, Middle Eastern, North African) but not Hispanic

African-American/Black (but not Hispanic)

Hispanic/Latino

Asian/Pacific Islander

Native American, Aleutian, Alaskan or Eskimo

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Card B

Excellent

Very Good

Good

Fair

Poor

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Card C

Extremely Helpful

Very Helpful

Somewhat Helpful

Not Very Helpful (because it was too confusing)

Not Very Helpful (because I knew the information already)

Not Applicable (did not receive written information)

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Card D

At All Times

Most Times

Sometimes

Rarely or Never

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Card E

Definitely Yes

Probably

Probably not

Definitely not

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Card F

Extremely difficult to understand

Difficult to understand

Easy to understand

Very easy to understand

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