Survey Example

This Survey can then be aggregated at the push of a button (Click Here to go to the next example)

Survey Example

Survey Example

Part A: Please circle one answer for each question. Thank you for spending the time to give information on the shelter.

1. How long was your stay in the shelter on this visit.

Less than one week.	1 to 2 weeks.	3 to 4 weeks.	More than 4 weeks.
0	1	2	3

Most women visit the shelter a number of times before they feel safe from their abuser.

2. Including this stay, how many times have you stayed in this or any other shelter?

This is my first time in any women's shelter	1 to 3 times in any women's shelter	4 to 7 times in any women's shelter	8 or more times in any women's shelter
0	1	2	3

3. Did you bring any children under the age of 18 with you into the shelter?

Yes

Only answer the following question if you have stayed at a women's shelter in the past.

4. If you have stayed at a shelter in the past, did you return to an abusive situation?

Yes	No	Not Sure
0	1	2

Only answer questions 5 and 6 if you answered "Yes" to question 4.

5. If you did return to an abusive situation, did you return to the situtation because of a lack of adequate resources?

Yes

6. Before this visit to the shelter, I knew what to do to keep to help keep myself and my family safe?

Not Applicable	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
0	1	2	3	4	5

7. Please choose the response that best describes the following: As a result of my shelter stay:

I feel safer.

Not Applicable	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
0	1	2	3	4	5

I better understand where to go for help.

Not Applicable	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
0	1	2	3	4	5

I better understand my legal rights.

Not Applicable	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
0	1	2	3	4	5

I better understand how to access services in the community for myself.

Not Applicable	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
0	1	2	3	4	5

I better understand how to access services in the community for my children.

Not Applicable	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
0	1	2	3	4	5

I can better recognize the signs of an abusive event.

Not Applicable	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
0	1	2	3	4	5

I better understand the impact the violence has had on my children.

Not Applicable	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
0	1	2	3	4	5

I better understand the impact the violence has had on me.

Not Applicable	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
0	1	2	3	4	5

I better understand what to do to keep to help keep myself and my family safe.

Not Applicable	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
0	1	2	3	4	5

As the final section of Part A, please answer the questions below.

8. Are you choosing to return to an abusive situation?

Yes

If you answered "Yes" to question 8, then answer the following two questions; otherwise proceed to Part B.

9. If you are choosing to return to an abusive situation, are you returning because of a lack of adequate resources.

Yes

10. If you are choosing to return to an abusive situation, are you returning because you have no other place to go?

Yes

Part B: Please answer the following questions. While you were at the women's shelter:

11. How did you find your accomodations?

Not Satisfied	Satisfied	Very Satisfied
0	1	2

12. Did you enjoy the atmosphere in the shelter?

Not Satisfied	Satisfied	Very Satisfied
0	1	2

13. Were the cousellors:

Friendly?

Yes

Helpful?

Yes

Supportive?

Yes

14. Were the staff sensitive to your cultural background?

Yes

15. Overall, how satisfied were you with the services you recieved at the women's shelter?

Quite Dissatisfied	Mildly Dissatisfied	Mostly Satisfied	Very Satisfied
0	1	2	3

16. If a friend were in need of similar help, would you recommend this shelter to her?

No, Definitely not	No, I do not thinks so	Yes, I think so	Yes, Definitely
0	1	2	3