OMB Control Number 0985-xxxx

Expiration Date: xx/xx/xx

OMB Control Number 0985-xxxx	Comment by ACL: 

Expiration Date: xx/xx/xx

# CLIENT QUESTIONNAIRE

Dear Client,

**If you are completing the form yourself**: The study team at New Editions Consulting would appreciate your feedback about your most recent interaction with [*name of APS Program*]. [*Description of APS program and types of services to cue the respondent, to the greatest extent possible, into answering the questions based on their experience with APS, rather than other services they may be receiving*]. Please take a few minutes to answer all of the questions on the next page by marking the rating that best matches your opinion. Please choose only one answer per question. Then, place the completed form in the pre-paid envelope and mail it to us. By submitting the form, you are agreeing to, or giving your consent, for your answers to become a part of our study. Your feedback will help us improve our work and will be kept completely private. Thank you for sharing your feedback!

**If you are completing the form on behalf of the APS client**: ACL would appreciate your feedback about the client’s most recent interaction with [*name of APS Program*]. [*Description of APS program and types of services to cue the respondent, to the greatest extent possible, into answering the questions based on their experience with APS, rather than other services they may be receiving*]. Please take a few minutes to answer all of the questions on the next page by marking the rating that you think best match the client’s opinion (put yourself in the client’s shoes). Please choose only one answer per question. Then, place the completed form in the pre-paid envelope and mail it to us. By submitting the form, you are agreeing to, or giving your consent, for your answers to become a part of our study. Your feedback will help us improve our work and your answers will be kept completely private. Thank you for sharing your feedback!	Comment by ACL: This should be edited. 	Comment by Washington, Tomakie (ACL): Corrected. Thanks much.

 [*Signature*]

## Public Burden Statement

According to the Paperwork Reduction act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reading instructions and responding to questions. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201, attention Stephanie Whittier Eliason, Administration for Community Living, Mary E. Switzer Room 1132A or email Stephanie.WhittierEliason@acl.hhs.gov and reference the OMB Control Number 0985-xxxx.

[*8-Digit Form Number*]

Please answer all of the questions below by marking the rating that best matches your opinion/the opinion of the client. Please choose only one answer per question.

9) Please let us know if you would like to share anything else about your experience with [*name of APS Program*].

______________________________________________________________________________

**Who completed this form?**□ Myself (client)*or*****□ Someone on behalf of the client

[*Pre-Populated**8-Digit Form Number*]