AGENCY WITH CHOICE (AWC) FINANCIAL MANAGEMENT SERVICES (FMS)
SATISFACTION SURVEY
We (_______ AWC FMS provider) are conducting an annual survey of your satisfaction with our
performance as your AWC FMS provider. The information you provide through this survey will be used
by us and the Pennsylvania Office of Developmental Programs (ODP) to evaluate your satisfaction with
the Participant Directed Services (PDS) and administrative services provided by us and to improve how
we serve you and others. Your response to this survey is very important in achieving this goal. Please
know that all of the information you provide will be considered confidential.
This survey was developed by ODP. Each Waiver funded AWC FMS is required to conduct a
satisfaction survey annually with each individual/surrogate receiving administrative services from the
AWC FMS. This is your annual survey, dated _______________.
(mo/yr)
This satisfaction survey is available in alternative formats (i.e., large print, on a computer disc,
administered by phone or in-person) or for translation services upon request. If you would like to
receive the survey in an alternative format, please call (___________________________)
Individual to contact at AWC/FMS
at (
) ___________ to request one.
Please complete the survey and return it in the enclosed self-addressed and stamped envelope by
_______________________. Should you have any questions about completing this survey, please do
not hesitate to call ______________________________ at (
) _____________.
If you would like to obtain a copy of the results of the surveys, please contact us to request a copy.
Thank you for your time and effort in completing and submitting this survey!
SECTION A: MANAGING EMPLOYER INFORMATION
1.
Who is the person completing this survey? (Please check only one box)
□ The individual receiving services.
□ The surrogate /managing employer of the individual receiving services.
□ The individual receiving services and the individual’s surrogate/managing employer completed
the survey together.
□ Other (please specify relationship to individual) ____________________________________
SECTION B: SATISFACTION WITH AWC FMS PROCESSING SSWS, PROVIDING INFORMATION
AND TRAINING
Note: Please circle only one answer for each question.
2.
Have you hired a new SSW within the past year?
1 - No
2 - Yes
If you answered yes, please answer questions 2(a) and 2(b). If you said no, proceed to question 3.
2 (a) If yes, how satisfied were you with the time it took us to process the paperwork for your SSW to
begin work?
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02/15/16
1 - Very
dissatisfied
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
Satisfied
2 (b) How satisfied were you with the time it took for your qualified SSW(s) to receive their first paycheck
from us?
1 - Very
dissatisfied
3.
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
Did we utilize the Pennsylvania Guide to Participant Directed Services and all corresponding forms
and documents to explain all of your responsibilities as a managing employer?
1 - No
2 - Yes
4. Did we explain and provide you with the current ODP SSW wage and benefit range informational
packet?
1 - No
5.
How satisfied are you with the Managing Employer Skills training you have received from us? * N/A
indicates you have not received Managing Employer Skills training within the past year
1 - Very
dissatisfied
6.
2 - Yes
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
Not applicable
N/A*
Please use the space below to suggest any improvements to our processing, information provision
and training as described in questions 3-5. If additional space is needed, please write on the back of
this page.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
SECTION C: SATISFACTION WITH SERVICES PROVIDED BY THE AWC FMS
Note: Please circle only one answer for each question.
7.
Have we clearly identified and communicated who the staff person is that you should contact with
questions?
1 - No
2 - Yes
If you answered yes, please answer question 7(a). If you said no, proceed to question 8.
7 (a). If yes, how satisfied are you with how the contact person responds to your calls including requests
for assistance and complaints?
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6/18/12
1 - Very
dissatisfied
8.
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
How satisfied are you with how we process and pay (i.e., accuracy and timeliness) your qualified
SSWs’ payroll checks? * N/A indicates you do not currently have any SSWs
1 - Very
dissatisfied
9.
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
Not applicable
N/A*
How satisfied are you with how we process and pay all other payments, including reimbursement
for transportation (mile) or other vendor services? * N/A indicates you have not used these services
within the past year
1 - Very
dissatisfied
10.
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
Not applicable
N/A*
How satisfied are you with the monthly utilization reports (i.e., accuracy, timeliness and format) that
we provide to you? * N/A indicates you have not had the opportunity to receive a monthly
utilization report due to recent enrollment (less than 30 days) with us
1 - Very
dissatisfied
11.
2 - Somewhat
dissatisfied
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
Not applicable
N/A*
Have any of your SSWs been dismissed from employment by us initiating the dismissal in the past
year?
1 - No
2 - Yes
If you answered yes, please answer question 11(a)and (b). If you said no, proceed to question 12.
11(a). If yes, how satisfied are you with how we notified you of the dismissal?
1 - Very
dissatisfied
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
11(b). If yes, how satisfied are you with how we conducted the dismissal?
1 - Very
dissatisfied
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
12. If a friend were interested in using the AWC FMS model, would you have positive feedback about our
agency to share with them?
1 - No
2 - Yes
13. Please use the space below to suggest improvements to our AWC FMS services described in
questions7-12. If additional space is needed, please write on the back of this page.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
SECTION E: SATISFACTION WITH LEVEL OF PARTICIPATION IN MANAGING YOUR SERVICES
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6/18/12
Note: Please circle only one answer for each question.
14. How satisfied are you with your level of participation in:
(a). recruiting qualified SSWs and referring them to us for hire? * N/A indicates you have not
recruited any SSWs this past year
1 - Very
dissatisfied
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
Not applicable
N/A*
(b). training you were able to provide to your qualified SSWs? * N/A indicates that no SSWs have
not worked with you this past year
1 - Very
dissatisfied
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
Not applicable
N/A*
(c). determining your qualified SSWs’ work schedules? * N/A indicates that no SSWs have worked
with you this past year
1 - Very
dissatisfied
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
Not applicable
N/A*
(d). negotiating your qualified SSWs’ wages and benefit allowances within the ODP established
range? * N/A indicates your qualified SSWs were already employed by another individual who uses
your AWC FMS, so you were not able to negotiate the qualified SSWs’ wages and benefit
allowances or when your qualified SSWs wage was outside of the ODP established range.
1 - Very
dissatisfied
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
Not applicable
N/A*
(e). approving, signing and submitting your qualified SSWs’ time sheets to us? * N/A indicates that
no SSWs have worked with you this past year
1 - Very
dissatisfied
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
Not applicable
N/A*
(f). supervising your qualified SSWs? * N/A indicates that no SSWs have worked with you this past
year
1 - Very
dissatisfied
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4 - Somewhat
satisfied
5 - Very
satisfied
Not applicable
N/A*
(g). evaluating the performance of your qualified SSWs? * N/A indicates that no SSWs have
worked with you this past year
1 - Very
dissatisfied
2 - Somewhat
dissatisfied
3 - Neither satisfied
nor dissatisfied
4
4 - Somewhat
satisfied
5 - Very
satisfied
Not applicable
N/A*
6/18/12
15.
Please use the space below to suggest any improvements on how we could improve the level of
participation as described in questions 14 (a)-(g). If additional space is needed, please write on the
back of this page.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Thank you again for your time and effort in completing this important survey!
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