Berks Deaf & Hard of Hearing Services
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Client Services Survey
*
Indicates required field
Name (optional)
*
First
Last
Male or Female?
*
Male
Female
Zip Code
*
What is your age group?
*
0-59
60-64
65+
What services did you receive from BDHHS?
*
Assistive Device
Hearing Aid
Daily Activities
Other
If Other please specify:
*
Assisitive Devices (doorbell alert, smoke/fire detector, alarm clock, telephone device, or other)
Are you able to maintain your independence through the Assistive Devices provided to you by BDHHS?
*
Do not agree
Agree
Strongly agree
Was staff knowledgeable of the Devices?
*
Yes
No
Hearing Aid
Choose all that apply
*
Hearing Aid Repair
One Hearing Aid
Two Hearing Aids
Did you get your Hearing Aids from Berks Deaf & Hard of Hearing Services?
*
Yes
No
Has your hearing quality improved by receiving Hearing Aids?
*
Yes
No
Did you qualify for the Hear Now Program?
*
Yes
No
If you did not qualify, what was the reason?
*
Has your Hearing Aid(s) helped you in situations you most wanted to hear?
*
Did not help
Helped silghtly
Helped quite a lot
Helped very much
Daily Activities (reading mail, phone calls, government assistance, etc.)
Was BDHHS helpful to you and/or your family in making informed decisions about your issues, needs or concerns?
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Not helpful
Somewhat helpful
Very helpful
Was service preformed in a timely matter?
*
Yes
No
Please rate how much BDHHS has improved your quality of life.
*
Not improved
Somewhat improved
Much improved
Do you think the services at BDHHS has improved the quality of your life?
*
Do not agree
Agree
Strongly agree
Comment / Suggestions
*
Submit
