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.
Section A:
1. Staff respected my background (e.g. gender, race, culture, ethnicity, sexual orientation, disability, lifestyle, etc.).
Clear selection
2. Services were available at times that were good for me.
Clear selection
3. I was asked to participate in deciding what services I would receive.
Clear selection
4. I feel the staff heard me.
Clear selection
5. I received the kind of service I wanted.
Clear selection
6. Staff helped me believe that my life could change for the better.
Clear selection
7. The services I received helped me deal more effectively with problems.
Clear selection
8. Because of the services I received, I learned coping skills to help me deal with trauma.
Clear selection
9. The services I received helped me identify a support system.
Clear selection
10. The services I received helped me become aware of how crisis and trauma affect my life.
Clear selection
11. The services I received helped me plan for my safety.
Clear selection
12. The staff informed me about Victims' Rights.
Clear selection
13. The services I received helped me cope with my fear for my safety.
Clear selection
14. Because of the services I received, I know more about the options and choices available to me overall.
Clear selection
15. I would return to this agency if I needed victim services in the future.
Clear selection
16. I would recommend this agency to a friend in need of victim services.
Clear selection
17. In an overall, general sense, I am satisfied with the services I received.
Clear selection
18. Because of the services I received, I know about community resources that are available to me.
Clear selection
Is there anything else you would like to say?
Section B:
If you visited our facility, please answer the following questions. If you never visited our facility, skip to Section C.
19. I was able to get around the building easily.
Clear selection
20. The facilities were comfortable for me.
Clear selection
Is there anything else you would like to say?
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.
21. I felt supported through the medical system by staff from the agency.
Clear selection
22. 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?
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.
23. I felt supported through the legal system by staff from the agency.
Clear selection
24. 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?
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 financial losses, please skip to Section F.
• Medical expenses • Loss of support • Transportation expenses
• Home healthcare • Funeral expenses • Childcare
• Counseling fees • Crime scene cleanup fees • Replacement of medical devices
• Loss of earnings • Relocation expenses
• Replacement services (of normal daily household chores – cooking, lawn care, cleaning, etc.)
25. The agency made me aware of the Pennsylvania Victim Compensation Program.
Clear selection
26. The information provided by the agency helped me understand the victim compensation process.
Clear selection
Is there anything else you would like to say?
Section F: In the past week...
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 choose one answer for each question.
27. In the past week, how much have you been bothered by unwanted memories, nightmares or reminders of the event?
Clear selection
28. 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?
Clear selection
29. 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?
Clear selection
30. In the past week, how much have you been bothered by poor sleep, poor concentration, jumpiness, irritability or feeling watchful around you?
Clear selection
31. In the past week, how much have you been bothered by pain, aches or tiredness?
Clear selection
32. In the past week, how much would you get angry or upset when stressful events or setbacks happened to you?
Clear selection
33. In the past week, how much have you been blaming yourself or feeling guilty for what happened to you?
Clear selection
34. In the past week, how much have the above symptoms interfered with your ability to work or carry out daily activities?
Clear selection
35. In the past week, how much have the above symptoms interfered with your relationships with family or friends?
Clear selection
36. How much better do you feel since beginning services? (as a percentage) 0% meaning no change and 100% meaning 'As well as I could be'.
37. Overall, how much have the above symptoms improved since starting services?
Clear selection
Section G
What did you find helpful about our services?
What did you find not helpful about our services? Please include any suggestions you have for improvement.
CLIENT DEMOGRAPHICS
Type of Victimization
Clear selection
Type of Service Received
Clear selection
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy