Form AAA-1230A FORNA "Exit Interview Questionnaire" - Arizona

What Is Form AAA-1230A FORNA?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2012;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form AAA-1230A FORNA by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form AAA-1230A FORNA "Exit Interview Questionnaire" - Arizona

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AAA-1230A FORNA (1-12)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Aging and Adult Services
Arizona Long Term Care Ombudsman Volunteer Program
EXIT INTERVIEW QUESTIONNAIRE
The Ombudsman Program continually strives to improve the performance of our volunteer system. As one of our
volunteers, we would appreciate your help in identifying areas in which we can improve and feedback on what is working.
Please be as complete and honest as possible. All of the information collected will be kept strictly confidential.
Name:
Date:
1. Approximately how long did you volunteer with us?
2. Reason you are leaving:
Commitment period is complete
Medical/Health issues
Personal
OR
Did not enjoy the volunteer experience
Did not feel well utilized
Other time commitments
Needed a change
Did not feel welcome (By whom?) ______________________________________________________________
Other:
3. What did you like best about volunteering with us?
4. What did you like least?
5. What suggestions would you make for changes or improvements in our volunteer efforts?
6. Overall, how would you rate your experience in volunteering with us.
Poor
Average
Good
1
2
3
4
5
7. Would you recommend becoming an Ombudsman volunteer to others?
Yes
No
Comments:
Thank you for volunteering with us!
Your honesty when completing this questionnaire will help us in the future to assist our clients and our community.
See reverse for EOE/ADA/LEP/GINA disclosures
AAA-1230A FORNA (1-12)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Aging and Adult Services
Arizona Long Term Care Ombudsman Volunteer Program
EXIT INTERVIEW QUESTIONNAIRE
The Ombudsman Program continually strives to improve the performance of our volunteer system. As one of our
volunteers, we would appreciate your help in identifying areas in which we can improve and feedback on what is working.
Please be as complete and honest as possible. All of the information collected will be kept strictly confidential.
Name:
Date:
1. Approximately how long did you volunteer with us?
2. Reason you are leaving:
Commitment period is complete
Medical/Health issues
Personal
OR
Did not enjoy the volunteer experience
Did not feel well utilized
Other time commitments
Needed a change
Did not feel welcome (By whom?) ______________________________________________________________
Other:
3. What did you like best about volunteering with us?
4. What did you like least?
5. What suggestions would you make for changes or improvements in our volunteer efforts?
6. Overall, how would you rate your experience in volunteering with us.
Poor
Average
Good
1
2
3
4
5
7. Would you recommend becoming an Ombudsman volunteer to others?
Yes
No
Comments:
Thank you for volunteering with us!
Your honesty when completing this questionnaire will help us in the future to assist our clients and our community.
See reverse for EOE/ADA/LEP/GINA disclosures
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination
in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,
genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part
in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters
for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will
take any other reasonable action that allows you to take part in and understand a program or activity, including making
reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity
because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in
alternative format or for further information about this policy, contact 602-542-6454; TTY/TDD Services: 7-1-1. • Free
language assistance for DES services is available upon request.
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