Spreadsheet: 005cf4c4-e78f-4a3b-81ab-3c3f35a94a86
Sheet: Oct 2011

 |  |  |  | Empowerment and Satisfaction Questionnaire-Long Form (ESQ-LF)
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Client Demographics |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Client Demographics
 | Date | Client # |  | Section A |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Section B |  | Section C |  | Section D |  | Section E |  | Section F |  |  |  |  |  |  |  |  |  |  |  |  | Type of Victimization |  |  |  |  |  |  |  |  | How long did you receive  services from our agency? |  |  |  |  |  | Type of Services Received |  |  |  |  |  |  |  |  | Have you had Prior Sexual Victimization? |  | Gender |  |  |  | Disability |  |  | Primary Income Source |  |  |  |  |  |  | Ethnic/Origin |  |  |  |  |  |  |  | Martial Relation (if adult) |  |  |  |  |  |  |  | Education |  |  |  |  |  |  |  |  | Household Income
 |  |  |  | 1.                   Staff Respected my background | 2.              Services were available | 3.                          I was asked to participate | 4.                          I feel staff    heard me | 5.                          I received service I wanted | 6.                     Staff helped     me believe | 7.                     The Services I received helped | 8.                          I learned    coping skills | 9.              Services helped identify support | 10.               Aware of trauma  impact | 11.            Helped me plan for safety | 12.                  Staff informed me of rights | 13.              Helped me cope with fear | 14.                         I know more about options | 15.                         I would return to agency | 16.                  I would recommend | 17.              Overall satisfied with services | 18.                        I know about resources | 19.                                I was able to get around | 20.                           The facility was comfortable | 21.                                 supported through  medical system | 22.                             I know more about medical system | 23.        Supported through legal | 24.                  Know more   about legal | 25.                     Aware of   Victims Comp | 26.                           Agency helped me understand VC | 27.          Bothered by memories | 28.                 Effort to avoid thinking | 29.                         Lost enjoyment, felt sad | 30.         Bothered by poor sleep | 31.                Pain, aches, or tiredness | 32.                  How often angry or upset | 33.           Blaming self or feeling guilty | 34.           Symptoms interfered  work | 35.           Symptoms interfered relat |  | 36.                    Do you feel better | 37.             Overall  symptoms improved |  | DV | SA | [NAME] | DUI victim | Caregiver | Physical assault | Child abuse (physical) | Robbery | Homicide Survivor | 0-3 months | 3-6 months | 6-12 months | 1-2 years | 2-4 years | More than 4 years | Crisis Counseling | Supportive Counseling | Victim Comp | Legal Advocacy | Shelter | Transitional Housing | Group Counseling | Individual Therapy | Medical [NAME] | Yes | No | Date of Birth | Male | Female | Other | Mental/Emotional | Physical | Other | Employment | Pension/ Retirement | Support | Social Security | Unemployment | Public Assistance | Other | Black/African American | White | Hispanic/ Latino(a) | Asian or Pacific Islander | American Indian/ Alaska Native | Bi-racial | Other | Unknown | Married | Living with Partner | Separated | Relationship/not living with partner | Divorced | Single | [NAME] | Other | No GED or High School | High School | GED | College Degree | Some College | [NAME] | Some Graduate | Post Graduate | Unknown | Less than $5000 | $5000-$9999 | $10,000-$14,999 | $15,000-$19,999 | $20,000-$24,999 | $25,000-$29,999 | $30,000-$49,999 | Over $50,000 | Unknown
 | Individual Question Mean |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Demographics Totals
 |  |  |  | Mean  SA Outcome #1: Victims/Survivors will report increased coping and sense of empowerment. |  |  |  |  | Mean SA Outcome #2: Victims/Survivors report that symptoms related to victimization have improved since starting services. |  |  |  |  | Victims Comp Outcome: The agency made me aware of the PA Victim compensation Program. The information provided by the agency helped me to understand the Victim Comp process |  |  |  |  | Legal advocacy outcome: I felt supported through the legal system by staff from the agency.  Because of the services I received, I now know more about the legal system. |  |  |  |  | Mean DV outcome: The services I received helped me plan for my safety. Because of the services I recieved, I know about community resources that are available to me