Clay County Rehabilitation Center, Inc.
#1 Commercial Drive
P.O. Box 659
Flora, Illinois 62839
Phone: 1.618.662.4916

I am:

Customer

Regulatory/Funding Agent

Other Interested Individual

To which program does your feedback pertain? Please mark all that apply.

	Developmental Training		Regular Work
	Evaluation		Secondary Transitional Education
	Supported Employment		Work Adjustment Training
	Specialized Services		Community Living Services

1. Are staff members courteous to you and your family member(s)?

YesNo Needs ImprovementNot Applicable

2. Are our buildings easy to use even if you have physical disabilities?

YesNo Needs ImprovementNot Applicable

3. Do the buildings appear clean and well maintained?

YesNo Needs ImprovementNot Applicable

4. Are your questions answered promptly?

YesNo Needs ImprovementNot Applicable

5. Do you feel you are given an opportunity to provide input and feedback to our Agency?

YesNo Needs ImprovementNot Applicable

6. Are you satisfied that your family member is safe while receiving services from our Agency?

YesNo Needs ImprovementNot Applicable

7. Are you invited to participate in the service planning process?

YesNo Needs ImprovementNot Applicable

8. Do we provide information to you in a timely manner?

YesNo Needs ImprovementNot Applicable

9. Does our Agency respect the privacy of you and your family member(s)/friend(s)?

YesNo Needs ImprovementNot Applicable

10. Are you satisfied with the service provided to your family member(s)/friend(s)?

YesNo Needs ImprovementNot Applicable

Are there any additional comments and/or suggestions that you care to make?