What was the date of your call to First Call/211?

-- mm/dd/yy

Choose the most pressing problem or need you had when you called. If nothing fits, then choose Other Information and please specify.

Abuse/Neglect Day Care/Child Care Disability Issues Education Emergency Employment Financial Assistance Food Health/Medical Housing Legal Mental Health Rape Recreation/Social/Clubs/Organizations Relationships Sexuality Substance Abuse Suicide Transportation Other Information

If other, please specify:

Did the Volunteer (who you talked to) offer referrals to meet your problem/need?

Yes No

Did you contact (call or visit) any of the referrals?

Yes No

If not, why not?: 

Choose the response that reflects how satisfied you were with our First Call/211 services:

The Volunteer understood the nature of my problem/need.

Very Dissatisfied    Dissatisfied    Neutral    Satisfied      Very Satisfied

The Volunteer helped me feel comfortable talking about my problem/need.

Very Dissatisfied   Dissatisfied    Neutral     Satisfied      Very Satisfied

The Volunteer asked me questions to determine my eligibility for community programs/services:

Very Dissatisfied   Dissatisfied    Neutral     Satisfied     Very Satisfied

Overall, how satisfied are you with the service provided to you by the Volunteer you talked with?

Very Dissatisfied   Dissatisfied    Neutral     Satisfied     Very Satisfied

Did you receive the help you were seeking from at least one of the agency/programs to which you were referred?:

Yes
No (if no, specify reason below)
Somewhat

If no, please select the reason from the list.

Agency full, I am on a waiting list I was ineligible for their services No financial assistance available No program found to meet my need Other reason

If Other Reason, please specify:

How did you first learn about First Call/211?:

Another agency Friend/relative Called before Internet Newspaper Phone Book Poster/Flyer Radio/TV Public Presentation (Speaker Squad) Word of Mouth Unknown Other (please specify)

If other, please specify: 

What, if anything, could First Call/211 do differently?:

Would you tell others about First Call/211?:

Yes No

Please select one of the following:

I am calling for the first time I have called before

Please select one of the following:

I called to help myself/my family I called to help someone else

General Comments (please add anything here that you would like to say.):

Please tell us a little about yourself:

Gender:         Male Female

Age Range:  0-12 13-18 19-22 23-30 31-40 41-50 51 and over

Indiana County ( for example, Tippecanoe).  If state other than Indiana, please indicate state and county.            

Make sure you have completed all the answers and then click on the Submit Form button ONCE.