QSR Participant Feedback Form
Thank you for your recent participation in (Name of County Agency) Quality Service Review which was held in (Month and Year). The input and feedback received during your interview is helpful in improving our services to families. We are also interested in gathering feedback from people who were interviewed for our review so that we can improve this process. Please take a moment to complete the following survey and return your survey in the enclosed envelope. Your responses are confidential. Please do not include your name.
Please identify your role in the Quality Service Review:
Child/Youth / Bio Parent / Family Member / Foster Parent / County WorkerCounty
Supervisor / School
Personnel / Medical
Personnel / Mental Health
Professional / Private Provider
Worker/Sup
Child Advocate
Social Worker / Child Advocate
Attorney / Parent Attorney / City Solicitor / Other(please explain):______
Please Rate:
1. The person who scheduled my interview treated me with respect.
1=Strongly Agree 2=Agree 3=Disagree 4=Strongly Disagree
2. The person who scheduled my interview explained the purpose and the process of the Quality Service Review in a way that I understood.
1=Strongly Agree 2=Agree 3=Disagree 4=Strongly Disagree
3. My interview was scheduled at a time and place that was convenient for me.
1=Strongly Agree 2=Agree 3=Disagree 4=Strongly Disagree
4. The people who interviewed me treated me with respect during my interview.
1=Strongly Agree 2=Agree 3=Disagree 4=Strongly Disagree
5. The people who interviewed me explained the purpose and the process of the Quality Service
Review to me in a way that I understood.
1=Strongly Agree 2=Agree 3=Disagree 4=Strongly Disagree
6. The people who interviewed me were on time in arriving for my interview.
1=Strongly Agree 2=Agree 3=Disagree 4=Strongly Disagree
7. I felt comfortable with openly sharing my experiences during my interview.
1=Strongly Agree 2=Agree 3=Disagree 4=Strongly Disagree
8. I was able to share all of the information that I felt was important with the people who were interviewing me.
1=Strongly Agree 2=Agree 3=Disagree 4=Strongly Disagree
9. I felt as though my thoughts and opinions mattered and were heard during my interview.
1=Strongly Agree 2=Agree 3=Disagree 4=Strongly Disagree
Please Comment:
10. What feedback would be helpful for you to receive from this review process? (Please note that due to the confidentiality of the interviews, we are unable to release information about specific case issues).
11. What did you like most about the Quality Service Review process?
12. What did you like least about the Quality Service Review process?
13. What suggestions do you have to improve this process?
Please Rate: For County Workers and Supervisors Only
14. I felt that the reviewers’ recommendations given to me at the end of the review process were helpful.
1=Strongly Agree 2=Agree 3=Disagree 4=Strongly Disagree
15. I plan to follow through with the recommendations given to me at the end of the review.
1=Strongly Agree 2=Agree 3=Disagree 4=Strongly Disagree
Pennsylvania’s QSR Manual Version 1.0 Appendix 22b