IYJ Program Feedback Form- Caregiver

IYJ Program Feedback Form- Caregiver
This form asks for feedback on how the program was administered and on the worker who assisted you.
Your Name
First NameLast Name
Youth's Name
First NameLast Name
Relationship to Youth
Approximate amount of time youth has been in your care.
IMPORTANT: Your personal information (i.e. name, phone number, address, etc...) will be kept confidential. General feedback may be shared with program supervisors and/or workers to help improve program services.

1a. Program Feedback- Please rate the following areas.

	Needs Improvement	Somewhat Satisfied	Satisfied	Very Satisfied
Program was customized to meet individual goals and youth/caregiver preferences
Support was provided for how to address youth behaviors
Updates and information were readily available or made available promptly
Data tracking was explained and well managed
Space was given for collaboration in the interventions used for helping the youth achieve program goals.

1b. Please write any additional comments or suggestions for improving the program in the space provided below.

2a. IYJ Work Feedback- Please rate the following areas.

	Needs Improvement	Somewhat Satisfied	Satisfied	Very Satisfied
Was the worker available for your and the youth's program needs?
Was the worker timely in responding to questions or requests?
Was the worker professional in speech and dress?
Did the worker provide opportunity for collaboration on meeting program goals?
Did the worker supply updates of progress as requested?

2b. Please write any additional suggestions or comments for what you liked or would have liked to see more of from your program worker in the space provided below.
Should be Empty: