Shelter Resident Exit Survey
Thank you for your help! Although doing this is voluntary, your answers to these questions will help our program understand and improve the services we provide. We do not ask for your name. your answers are confidential are very important us. Please respond honestly. When you have finished, put this form in the envelope you were given, seal it, and put it in the place the staff member showed you.
- Approximate number of days you stayed in this shelter this stay: _______________
___ ___ ___ ___ (Write in the first 2 letters of your mother’s first name, and the first 2 numbers of your most recent address, e.g., WE17. No one will be able to connect this information with you, but it will allow us to better meet resident’s needs. If you still do not feel comfortable with this, please use two letters followed by two numbers that you will remember and can use again later. If you filled out the Intake survey (survey #1). Please use the same letters and numbers you used then.
- The following list describes different types of services you may have wanted and may have received while you were in the shelter. Every woman wants and needs different things, so there are no “right” answers. Please rate each of the items on the list according to the help you received with:
| We ask the next questions to see if different women have different experiences here, so we can continue to improve our services for ALL women. But please leave any blank if you are concerned it |
___ safety for myself ___ transportation
___ safety for my children ___ support from other women
___ learning about my options and choices ___ a job or job training
___ paying attention to my own wants and needs ___ counseling for myself
___ paying attention to my children’s wants
and needs ___ counseling for my children
___ understanding about domestic violence ___ emotional support for myself
___ safety planning ___ health issues for myself
___ education/school for myself ___ health issues for my children
___ education/school for my children ___ my abuse-related injuries
___ reconnecting with my community ___ leaving my relationship
___ budgeting & handling my money ___ TANF (welfare) benefits
___ child protection system issues ___ other government benefits
___ child welfare system issues ___ legal system/legal issues
___ protective/restraining order ___ my abuser’s arrest
___ my own arrest ___ custody or visitation questions
___ divorce-related issues ___ immigration issues
___ ideas for handling the stress in my life ___ childcare
___ connections to other people who can help me ___ finding housing I can afford
___ responding to my children when they are upset
or causing trouble ___ other (what?): __________
- What about the shelter has made you feel the most comfortable? _______________
_____________________________________________________________________
- Because of my experience in the shelter, I feel (please check yes or no):
Yes No ___ ___ I know more ways to plan for my ___ ___ I know more about community ___ ___ more confident in my decision-making ___ |
Comments: ____________________________________________________________
______________________________________________________________________
- Because of our time in the shelter, I think my children (check yes or no, or check “doesn’t apply – no children”):
Yes No ___ ___ are better able to express their ___ ___ have |
Comments: ____________________________________________________________
______________________________________________________________________
- Please circle the number that best reflects your agreement of disagreement with the following statements:
doesn’t apply | strongly disagree | disagree | agree | strongly agree | |
Shelter staff treated me with respect. | 0 | 1 | 2 | 3 | 4 |
Shelter staff were caring and supportive. | 0 | 1 | 2 | 3 | 4 |
Shelter staff spent enough time talking about my safety | 0 | 1 | 2 | 3 | 4 |
Shelter staff spent enough time talking about my children’s safety | 0 | 1 | 2 | 3 | 4 |
Over all, my religious/spiritual beliefs were respected. | 0 | 1 | 2 | 3 | 4 |
Over all, my sexual orientation was respected. | 0 | 1 | 2 | 3 | 4 |
Over all, my racial/ethnic background was respected. | 0 | 1 | 2 | 3 | 4 |
Shelter staff helped address any needs related to my disability | 0 | 1 | 2 | 3 | 4 |
Shelter staff helped address any needs related to my youth or advancing age | 0 | 1 | 2 | 3 | 4 |
- Overall, thinking about my stay here, I would rate the help I received at this shelter as:
___ Very helpful ___ Helpful ___ A little helpful ___Not at all helpful
Comments: ____________________________________________________________
______________________________________________________________________
- If a friend of mine told me she was thinking of coming her for help, I would: (please check one):
___ Strongly recommend she come ___ Recommend she come
___ Recommend she not come ___ Strongly recommend she not come
Comments: ____________________________________________________________
______________________________________________________________________
- The shelter staff try to make your stay as helpful as possible. However, every woman’s situation is different, and sometimes problems can occur, even in the best of programs. The list describes different types of problems you may have experienced while you were in the shelter. Please let us know about any problems you experienced, using the numbered ratings for each item on the list. Please be honest and add your comments!
Please put one of these numbers on the space next to each type of problem listed below:
3 = This was not a
problem for me 1
= This was a problem, and it was not resolved to my satisfaction
- Problems related to rules about – Comments
___ Curfew __________________________________
___ Childcare (what?) __________________________________
___ Child discipline and monitoring __________________________________
___ Chores __________________________________
___ Time limits on staying here __________________________________
___ Going to my job or school __________________________________
___ Telephone privileges __________________________________
___ Contact with my abusive partner __________________________________
___ Contact with family or friends __________________________________
___ Allowing teen boys to stay here __________________________________
___ Other (what?): ________________ __________________________________
- Problems related to other concerns –
___ Conflict with other women in shelter __________________________________
___ Conflict with staff __________________________________
___ Lack of respect for my customs/practices __________________________________
___ Choices of food available __________________________________
___ Need for transportation __________________________________
___ Communicating (e.g. language barriers) __________________________________
___ Difficulties getting around in the shelter __________________________________
___ Finding privacy __________________________________
___ Other (what?): _________________ __________________________________
We ask the next questions to see if different
women have different experiences here, so we can continue to improve our
services for ALL women. But please leave any blank if you are concerned it
- I consider myself to be:
___ African American/Black ___ Asian
___ African ___ Asian American
___ Native American/Alaska Native ___ Hispanic/Latinx
___ Middle Eastern ___ Native Hawaiian/Pacific Islander
___ Multiracial ___ White/Caucasian
___ Prefer not to answer ___ Another identity (please specify): _____
If there is a particular ethnic background that is important to you, please identify: _____
- My age is:
___ 18-24 ___ 25-34 ___ 34-44 ___ 44-54 ___ 55-64 ___ 65+ ___ Prefer not to answer
- I am:
___ Cisgender woman ___ Cisgender man
___ Transgender woman ___ Transgender man
___ Genderqueer/Non-Binary ___ Agender
___ Two-spirit ___ Another Identity (please specify): ___________
___ Prefer not to answer
- I have ________ minor children (age 17 or younger)
- How many are with you here? ________ (# of children)
- I consider myself to be
___ Straight ___ Bisexual ___ Gay/Lesbian/Queer ___ Prefer not to answer
___ Another (please specify): _________________
- The highest level of education I have so far is:
___8th grade or less
___ 9th-11th grade
___ High school graduate or GED
___ Some college
___ College graduate
___ Advanced degree
Thank you very much!!