Please print out these pages, fill out ,and return to us..
OCEAN STATE CENTER FOR INDEPENDENT LIVING (OSCIL)
1944 Warwick Avenue, Warwick, RI 02889
OSCIL values your feedback! Our Center wants to provide the highest possible quality services.
Please take a few moments to provide your feedback on our Center.
Mail, fax, or deliver to our office by October 19, 2008. Our fax number is 401-738-1083.
Please circle the response below that best describes your opinion of the services you have received from OSCIL by using the following:
1. As a result of my involvement with OSCIL, I am more independent in my home, or apartment/residence.
0 = Not applicable 1 = Strongly Disagree 2 = Disagree 3 = Agree 4 = Strongly Agree
2. As a result of my involvement with OSCIL, I am less dependent on others.
0 = Not applicable 1 = Strongly Disagree 2 = Disagree 3 = Agree 4 = Strongly Agree
3. As a result of my involvement with OSCIL, I am better able to move confidently around my house/apartment and/or community.
0 = Not applicable 1 = Strongly Disagree 2 = Disagree 3 = Agree 4 = Strongly Agree
4. As a result of my involvement with OSCIL, I am better able to manage
housekeeping tasks and maintain my house/apartment.
0 = Not applicable 1 = Strongly Disagree 2 = Disagree 3 = Agree 4 = Strongly Agree
5. As a result of my involvement with OSCIL, I am better able to care for my children
and family.
0 = Not applicable 1 = Strongly Disagree 2 = Disagree 3 = Agree 4 = Strongly Agree
6. As a result of my involvement with OSCIL, I am better able to participate in the life of
my family, friends and community.
0 = Not applicable 1 = Strongly Disagree 2 = Disagree 3 = Agree 4 = Strongly Agree
7. As a result of my involvement with OSCIL, I am no longer considering having to go
into a nursing home.
0 = Not applicable 1 = Strongly Disagree 2 = Disagree 3 = Agree 4 = Strongly Agree
8. As a result of my involvement with OSCIL, I am better able to advocate for myself
for what I need.
0 = Not applicable 1 = Strongly Disagree 2 = Disagree 3 = Agree 4 = Strongly Agree
9. What is your disability? (Check most appropriate answer.)
___ Cognitive/Brain Injury
___ Mental Health/Emotional
___ Physical
___ Hearing
___ Vision
___ Multiple Disabilities
10. How did you hear about us? (Check most appropriate answer.)
___ Family/Friend
___ State Agency
___ Media
___ Consumer
___ Conference Display/Exhibit
___ Other Service Provider ___________________________________
11. Why did you call or come in? _______________________________________________
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12. What is the greatest difference OSCIL has made in your life? __________________
___________________________________________________________________________
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13. Additional Comments:
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Thank you for your input!