The Gentry Facility/Assistive Technology Department
Consumer Satisfaction Survey

In order to help E. H. Gentry’s Assistive Technology Department maintain quality services we are gathering feedback from our consumers. Your participation in this survey is greatly appreciated and will mean a great deal to our program and the consumers we serve.

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Consumer Name *
1. Which of the following services did you receive (check all that apply)?
2. Where were your services provided (check all that apply)?
3. How did you receive these services (check all that apply)?
4. Did we serve you with care, courtesy and respect?
Clear selection
5. Did we respond to your need in a reasonable time?
Clear selection
6. Did we communicate with you in a way you could understand?
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7. Was our staff knowledgeable and well-trained?
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8. Have your assistive technology needs been resolved?
Clear selection
9. If you received assistive technology instruction, has this instruction helped you use your technology more effectively?
Clear selection
10. Did the services you received meet your individual needs?
Clear selection
11. Do you need any further services at this time?
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12. Are there any additional/new services or training courses you would like to see offered through our program? (please list)
13. If you answered “No” to any of questions 3 through 9, please explain your response here. Also, if you have any other comments you would like to share with us, please include them in this space.
Staff Use Only
The following questions are intended for staff use only. If you are completing the survey yourself, please leave this blank and submit the survey below.

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