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Date:

Name (Optional): ______________________________________________________


Your TIHC worker(s):___________________________________________________

The staff at Trinity In-Home Care thanks you for being our loyal client! We are always looking
for ways to improve our services. The goal of the survey is to hear about the quality of your
experiences with TIHC. Your input will help us determine how to better serve you. Please
answer as truthfully as possible and with as much detail as you like.
Thank you for taking time to complete this survey. The survey questions will reference:
The administrative staff (Megan Poindexter, Caitlin Schmidt, Karen Troutman, John
Pryor, and Janet Mills)
The worker(s) that come to your home.
If you have any questions or wish to complete the survey over the phone, you can contact
TIHC office at (785) 842-3159. You can also email answers or request a copy of this survey
from megan@tihc.org.
Please return this survey at your earliest convenience to:
Trinity In-Home Care
Megan Poindexter
2201 West 25th Street, Suite Q
Lawrence, KS 66047

On a scale of 1-5 (1= poor, 2 = fair, 3 = good, 4= very good, 5 = excellent) circle and complete the following
questions:
1. How would you rank your overall wellbeing?
a. Health

b. Emotional wellbeing

c. Quality of environment

d. How could TIHC help improve your wellbeing?

2. How would you rank your ability to perform everyday tasks?


1

Are there any additional tasks TIHC could assist you with?

3. How would you rank the overall quality of communication with administrative staff?
1

Describe your interactions with administrative staff. How could TIHC improve?

4. How would you rank the overall quality of communication with your worker?
1

How could communication with your worker be improved?

5. How would you rank your workers overall likeability?


1

Describe your workers personality:

6. How would you rank your workers ability to complete tasks?

Describe your workers performance:

Please circle and complete the following questions:


7. Do the services provided by TIHC help you remain comfortable and independent in your home?
Yes

No

Somewhat

Explain:

8. Do you feel that your quality of life has been improved as a result of TIHCs services?
Yes

No

Somewhat

Explain:

9. Does the administrative staff meet your scheduling needs in a helpful, timely manner?
Yes

No

Somewhat

Explain:

10. Are you happy with your workers overall performance?


Yes

No

Somewhat

Explain:

11. Do you understand the charges on your invoice? (including, if applicable, gas reimbursement or client
obligation)
Yes

No

Somewhat

What charges, if any, are unclear to you?

12. If you have experienced an invoice error, did TIHC resolve it in a clear, timely manner?
Yes

No

Somewhat

Explain

13. Do you have enough hours for your worker to complete their tasks?
Yes

No

Somewhat

Explain

14. What is your Medicaid case mangers name?

15. How many hours do you have per month?

16. List the tasks you have been approved for by Medicaid.

17. Overall, how would you rank your experience with TIHC? (1= poor, 2= fair, 3=good, 4= very good, 5=
excellent)
1
2
3
4
5
18. Do you have any final comments, concerns, questions, or suggestions that you would like the TIHC staff
to know?