Empowerment and Satisfaction Questionnaire-Long Form(ESQ-LF)
As a client of our agency, you received services in response to a traumatic event(s). In order to provide the best possible services, we would like to know how much our agency helped you to deal with that particular trauma. Please read the following statements about the services and other aspects of the agency and circle if you strongly agree, somewhat agree, are neutral (don't feel strongly one way or the other), somewhat disagree or strongly disagree with the statements.
Answers are not required for any of the questions, if you wish to skip a question, please feel free to do so. Please just remember to click submit at the very bottom of the survey.
Section A:
Strongly Disagree
Somewhat Disagree
Neutral
Somewhat Agree
Strongly Agree
Staff respected my background (e.g. gender, race, culture, ethnicity, sexual orientation, disability, ;lifestyle, etc.).
Services were available at times that were good for me.
I was asked to participate in deciding what services I would receive.
I feel the staff heard me.
I got the kind of service I wanted.
Staff helped me believe that I could change and improve my life.
The services I received helped me deal more effectively with problems.
Because of the services I received, I learned skills to help me better manage my life.
The services I received helped me identify a support system.
The services I received helped me become aware of how crisis and trauma affect my life.
The services I received helped me plan for my safety.
The staff informed me about my victims rights.
The services I received helped me cope with my fear for my safety.
Because of the services I received, I know more about the options and choices available to me overall.
I would return to this agency if I needed victim services in the future.
I would recommend this agency to a friend in need of victim services.
In an overall, general sense, I am satisfied with the services I received
Because of services I received, I know about community resources that are available to me.
Strongly Disagree
Somewhat Disagree
Neutral
Somewhat Agree
Strongly Agree
Staff respected my background (e.g. gender, race, culture, ethnicity, sexual orientation, disability, ;lifestyle, etc.).
Services were available at times that were good for me.
I was asked to participate in deciding what services I would receive.
I feel the staff heard me.
I got the kind of service I wanted.
Staff helped me believe that I could change and improve my life.
The services I received helped me deal more effectively with problems.
Because of the services I received, I learned skills to help me better manage my life.
The services I received helped me identify a support system.
The services I received helped me become aware of how crisis and trauma affect my life.
The services I received helped me plan for my safety.
The staff informed me about my victims rights.
The services I received helped me cope with my fear for my safety.
Because of the services I received, I know more about the options and choices available to me overall.
I would return to this agency if I needed victim services in the future.
I would recommend this agency to a friend in need of victim services.
In an overall, general sense, I am satisfied with the services I received
Because of services I received, I know about community resources that are available to me.
Clear selection
Is there anything else you would like to say?
Your answer
Section B: If you visited our facility, please answer the following questions. If you never visited our facility, Skip to Section C.
Strongly Disagree
Somewhat Disagree
Neutral
Somewhat Agree
Strongly Agree
I was able to get around the building easily.
The facilities were comfortable for me.
Strongly Disagree
Somewhat Disagree
Neutral
Somewhat Agree
Strongly Agree
I was able to get around the building easily.
The facilities were comfortable for me.
Clear selection
Is there anything else you would like to say?
Your answer
Section C: If someone from our agency met you at an emergency medical facility, please answer the following questions about the services we provided. If not, please skip to Section D.
Strongly Disagree
Somewhat Disagree
Neutral
Somewhat Agree
Strongly Agree
I felt supported through the medical system by staff from the agency.
Because of the services I received, I now know more about the medical system.
Strongly Disagree
Somewhat Disagree
Neutral
Somewhat Agree
Strongly Agree
I felt supported through the medical system by staff from the agency.
Because of the services I received, I now know more about the medical system.
Clear selection
Is there anything else you would like to say?
Your answer
Section D: If someone from our agency accompanied you through the legal process, please answer the following questions about the services we provided. If not, please skip to Section E.
Strongly Disagree
Somewhat Disagree
Neutral
Somewhat Agree
Strongly Agree
I felt supported through the legal system by staff from this agency.
Because of the services I received, I now know more about the legal system.
Strongly Disagree
Somewhat Disagree
Neutral
Somewhat Agree
Strongly Agree
I felt supported through the legal system by staff from this agency.
Because of the services I received, I now know more about the legal system.
Clear selection
Is there anything else you would like to say?
Your answer
Section E: If you had any of the following out-of-pocket (not covered by any type of insurance) financial losses as a direct result of the victimization, please answer the following questions. If you did not have any of these out-of-pocket losses, please skip to Section F.
Medical expenses
Home healthcare
Counseling fees
Loss of earnings
Loss of support
Funeral expenses
Crime scene clean up fees
Relocation expenses
Transportation expenses
Child care
Replacement of medical devices
Replacement services (of normal daily household chores-cooking, lawn care, cleaning, etc.)
Section E: (Continued)
Strongly Disagree
Somewhat Disagree
Neutral
Somewhat Agree
Strongly Agree
The agency made me aware of the Pennsylvania Victim Compensation Program.
The information provided by the agency helped me understand the victim compensation process.
Strongly Disagree
Somewhat Disagree
Neutral
Somewhat Agree
Strongly Agree
The agency made me aware of the Pennsylvania Victim Compensation Program.
The information provided by the agency helped me understand the victim compensation process.
Clear selection
Is there anything else you would like to say?
Your answer
Section F: Please consider the following reactions which sometimes occur after a traumatic event. This section is concerned with your personal reactions to the traumatic event which happened to you. Please answer the following questions
Not at All
A Little Bit
Moderately
Quite a Lot
Very Much
In the past week, how much have you been bothered by unwanted memories, nightmares, or reminders of the event?
In the past week, how much effort have you made to avoid thinking or talking about the event, or doing things which remind you of what happened?
In the past week, to what extent have you lost enjoyment for things, felt sad or depressed, kept your distance from people, or found it difficult to experience feelings?
In the past week, how much have you been bothered by poor sleep, poor concentration, jumpiness, irritability or feeling watchful around you?
In the past week, how much have you been bothered by pain, aches, or tiredness?
In the past week, how much would you get angry or upset when stressful events or setbacks happened to you?
In the past week, how much have you been blaming yourself or feeling guilty for what happened to you?
In the past week, how much have the above symptoms interfered with your ability to work or carry out daily activities?
In the past week, how much have the above symptoms interfered with your relationships with family or friends?
Not at All
A Little Bit
Moderately
Quite a Lot
Very Much
In the past week, how much have you been bothered by unwanted memories, nightmares, or reminders of the event?
In the past week, how much effort have you made to avoid thinking or talking about the event, or doing things which remind you of what happened?
In the past week, to what extent have you lost enjoyment for things, felt sad or depressed, kept your distance from people, or found it difficult to experience feelings?
In the past week, how much have you been bothered by poor sleep, poor concentration, jumpiness, irritability or feeling watchful around you?
In the past week, how much have you been bothered by pain, aches, or tiredness?
In the past week, how much would you get angry or upset when stressful events or setbacks happened to you?
In the past week, how much have you been blaming yourself or feeling guilty for what happened to you?
In the past week, how much have the above symptoms interfered with your ability to work or carry out daily activities?
In the past week, how much have the above symptoms interfered with your relationships with family or friends?
Clear selection
Section F (Continued): How much better do you feel since beginning services? (as a percentage)
0% No change
1
2
3
4
5
6
7
8
9
10
100% As well as I could be
Clear selection
Section F (Continued): Overall, how much have the above symptoms improved since starting services?
Very Much
Much
Minimally
No Change
Worse
Clear selection
What did you find helpful about our services?
Your answer
What did you find not helpful about our services? Please include any suggestions you have for improvement.
Your answer
Type of victimization (check all that apply to your current situation)
Domestic Violence
Sexual Assault
Child Abuse (sexual)
Caregiver of victim/survivor
Physical assault
Child abuse (physical)
DUI Victim
Robbery
Homicide Survivor
Primary income source
Employment
Pension/retirement
Support
Social Security
Unemployment
Public assistance
Other:
Clear selection
How long did you receive services from our agency?
0-3 months
3-6 months
6-12 months
1-2 years
2-4 years
more than 4 years
Clear selection
Ethnic Origin
White
Black/ African- American
Hispanic/Latino(a)
Asian or Pacific Islander
American Indian/ Alaska Native
Bi-racial
Unknown
Other:
Marital/Relation (if adult)
Married
Living with partner
Separated
Relationship, not living with partner
Divorced
Single
Widow/widower
Other:
Clear selection
Type of services received (check all that apply)
Crisis counseling
Supportive counseling
Victim compensation
Legal advocacy
Shelter
Group counseling
Medical advocacy
Have you had prior victimizations?
Yes
No
Clear selection
If yes, what type of prior victimizations have you encountered?
Your answer
Education
No GED or High school diploma
GED
High School
Some College
College Degree
Some Graduate
Graduate Degree
Post Graduate
Clear selection
Date of birth
MM
/
DD
/
YYYY
Household income
Less than $5,000
$5,000-$9,999
$10,000-$14,999
$15,000-$19,999
$20,000-$24,999
$25,000-$29,999
$30,000-$49,999
Over $50,000
Unknown
Clear selection
Gender
Female
Male
Prefer not to say
Other:
Clear selection
Disability
Mental/Emotional
Physical
Other:
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