SAFETY ALERT: If you are in danger, please use a safer computer and consider calling 911. The National Domestic Violence Hotline at 1-800-799-7233 / TTY 1-800-787-3224 or the StrongHearts Native Helpline at 1−844-762-8483 (call or text) are available to assist you. Please review these safety tips.

Shelter Residents Evaluation Form

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Evaluation Form for Shelter Residents

 

This is an anonymous questionnaire. Please do not put your name on it. We value your feedback, and the answers you provide will be used to improve the services we provide. Thank you in advance for taking the time to answer to the following questions. 

 

  1. I heard about this program through: ______________________

 

  1. How long have you been at the shelter? 

 

___ 1-14 days  

___ 15-28 days  

___ 29-42 days  

___ More than 42 days 

 

  1. How would you rate your experience with the crisis line:

 

___ Excellent  

___ Good  

___ Average  

___ Poor  

___ Didn’t use it 

 

  1. Please check the line under the response that best matches how you feel:

     Very Much   Some     A       Not

Because of the services I received through the shelter…..              /A lot        what     little       at All

 

I feel more supported.                                                                    ___          ___    ___        ___

I am more aware of community resources/services I might

need.                                                                                                ___       ___       ___        ___

I know more about my choices and options.                                ___       ___       ___        ___

I have a better understanding of common reactions to domestic

violence.                                                                                           ___       ___       ___        ___

I know more ways to plan for my safety.                                       ___       ___       ___        ___

I know people I can turn to for help and support.                              ___            ___       ___          ___

I have a plan to help me meet my financial and housing needs.     ___  ___       ___        ___

I am more hopeful about the future.                                            ___       ___       ___        ___

I feel more in control of my life.                                                     ___       ___       ___        ___

 

IF YOU HAD CHILDREN WITH YOU PLEASE ANSWER:

 

I learned more about how domestic violence may affect my

child(ren).                                                                                        ___       ___       ___        ___

My child(ren) have learned who to call and when to get help

when necessary.                                                                              ___       ___       ___        ___

  1. I am 

 

___ Cisgender woman                      ___ Cisgender man  

___ Transgender woman                 ___ Transgender man  

___ Genderqueer/Non-binary         ___ Agender  

___ Two-spirit                                   ­___ Prefer not to answer  

___ Another identity (please specify): __________  

 

  1. I am:

 

___ 18-24 years old  

___ 25-34 years old  

___ 35-44 years old  

___ 45-54 years old  

___ 55-64 years old 

___ 65+ years old  

___ Prefer not to answer  

 

  1. I consider myself to be:

 

___ African American/Black             ___ African  

___ Asian                                          ___ Asian American  

___ Hispanic/Latinx                          ___ Middle eastern  

___ Native American/Alaska Native   ___ Native Hawaiian/Pacific Islander  

___ White/Caucasian                       ___ Prefer not to answer

___ Another identity (please specify)  

 

 

  1. I am a person with (please check all that apply):

 

___ A physical disability  

___ A hearing disability  

___ A visual disability  

___ A cognitive disability  

___ An emotional/psychiatric disability  

___ An alcohol/chemical disability  

___ A learning/developmental disability  

___ No disability  

___ Other disability  

 

  1. Any additional comments/suggestions or statements?

 

 

 

 

 

 

      Please check this box is you give us permission to share your comments on PR materials/or funding reports. Again, this information will remain anonymous.  

 

Thank you again for taking the time to fill this out – we will use your comments to continue to improve our services! And please contact us if you should need anything.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
  

From the Domestic Violence Evidence Project of the National Resource Center on Domestic Violence

More evaluation tools and tips can be found at http://www.dvevidenceproject.org/evaluation9tools/

 

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