Impact Data Phone Survey

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Date / MM / DD YYYY
Name First Last
Address
Street Address

City

Zip Code
Phone - (###) - ### ####
Email
Child's Name First Last
Age of Child
Disability
Concern of Original Call:
Section Break
1.How useful was the information you received from your contact with the Parent Center? Very Useful Not Useful
Comments
2. The Parent Center provided me with the information I needed to make decisions abut my child’s education. Yes No
3.Because of information I received from the Parent Center, I am more knowledgeable about how to work with schools.
Checkboxes To a great extent To some extent Not at all
Comments
4.My Child has received more appropriate services because I have put to use the information I have learned from the Parent Center. Yes No
Comments
5.To what extent have you shared the information you received from the Parent Center with other families? To a great extent To some extent Not at all
Comments
6.The information and support I received from the Parent Center helped me to resolve a disagreement with the school. Yes No N/A - No disagreement
Comments
7. Because of the information I received from the Parent Center, I was able to work with the school to address a critical need related to my child’s education. Yes No N/A
Comments
8. The materials available from my Parent Center are of high quality. Yes No N/A - Did not receive materials
Comments
Additional Comments