Tennessee AgrAbility
Client Information Sheet
FORM A-Structure for collection of information from clients: (can be used on farm
visits, initial telephone calls, etc.; can be modified for individual situations)
Name:
DOB:
Address:
Telephone:
Email:
SSN:
Family members (and do they help on the farm):
Disability:
On SSDI: Y or N
Extension Director/Agent/County:
Other professionals currently working with:
Type of farm/Farm operation details:
What types of equipment do you operate/what facilities do you have?
How does your disability affect your farming?
Do you have any trouble with daily living activities/getting around in your home?
Financial Information:
In what ways would AgrAbility help you most (what are your needs at this time)?
Additional questions or notes (write in before visit):
FORM B – To structure client case notes (we’re already getting this info. –just a
way to organize and record):
1. What programs or services might be contacted to help this farmer?
2. What accommodations/recommendations were made?
3. Were/are other family members involved in this case? If so, who are they what is
their involvement?
4. How did you assure that any modifications made were well planned and safe?
5. Did you provide help in locating funding assistance? If so, what did you do?
6. Do you feel that you fully met this client’s needs? If no, why not?
(Need to see if what we do is what is needed – we’ll do this by comparing this answer by the farmer’s
answer to the “needs” question)
7. Do you feel that your services have made a difference in your client’s life? Please
briefly describe.
8. Did you feel that your knowledge was adequate to help this farmer? If not, what
would have helped?
AgrAbility Client Evaluation
Item #1 – Client questionnaire:
*Are you pleased with modifications/services provided?
Not pleased
Very pleased
1
2
3
4
5
6
7
No basis for
Judgement
?
*Did AgrAbility staff help you locate funding assistance?
Y
N
*If so, was it helpful and why?
*Did AgrAbility services meet your needs?
Strongly disagree
Strongly agree
1
2
3
4
5
6
7
No basis for
Judgement
?
*If not, please explain.
*Did AgrAbility staff member seem committed to helping you meet these needs?
Strongly disagree
Strongly agree
No basis for
Judgement
1
2
3
4
5
6
7
?
*Was AgrAbility staff member courteous?
Not courteous
Very courteous
1
2
3
4
5
6
7
*Was AgrAbility staff member accessible?
Not accessible
Easily accessible
1
2
3
4
5
6
7
*Have AgrAbility services helped you remain farming?
Strongly disagree
Strongly agree
No basis for
Judgement
?
No basis for
Judgement
?
No basis for
Judgement
1
2
3
4
5
6
7
?
*As a result of AgrAbility services, do you feel more knowledgeable about products or
services (not necessarily AgrAbility) available to help you?
Strongly disagree
Strongly agree
No basis for
Judgement
1
2
3
4
5
6
7
?
*How could we improve on our services?
Item #2 – AgrAbility client interview
Personal interview questions: For these, we mainly want the clients to describe to us in
their own words the experience of working with AgrAbility, and what was the result. (this
may not be used with all clients)
Has working with AgrAbility made an impact in your life?
Please describe what specifically has improved or not improved as a result of
AgrAbility services.
What did you like (and what did you dislike) about AgrAbility? What would
you like to see changed or improved upon? What else would have helped you?