ACCESS: Quality of Care Questionnaire

Quality of Care Questionnaire
Please fill out this form to help us evaluate our Volunteer Grief Mentor Program.
Thank you for your valuable participation in making ACCESS the best it can be!

Date:

Name:

Address:

City:

State: Zip:

Country:

Day Phone:

Eve Phone:

Fax:

* Email:
Best way to contact you? Day Phone Eve Phone Email

How did you hear about ACCESS?

Your Volunteer Grief Mentor (name):

Was the match appropriate?

Was she/he helpful? Yes No (please explain):

Do you have issues/concerns that you were not comfortable discussing with him/her?
(If so, please explain):

Suggestions for improving ACCESS:

Additional comments:

* To submit this form, please enter the characters you see in the image:

Thank you!

Date:
Name:
Address:
City:
State:	Zip:
Country:
Day Phone:
Eve Phone:
Fax:
* Email:
Best way to contact you? Day Phone Eve Phone Email
How did you hear about ACCESS?

Your Volunteer Grief Mentor (name):
Was the match appropriate?

Was she/he helpful? Yes No (please explain):

Do you have issues/concerns that you were not comfortable discussing with him/her? (If so, please explain):

Suggestions for improving ACCESS:

Additional comments:


* To submit this form, please enter the characters you see in the image:

Thank you!