Did the assessor clearly explain the nature and purpose of today’s assessment?*

Please explain:

Did the assessor conduct himself/herself in a professional manner?*

Please explain:

Were you provided with the opportunity to present all of your concerns and respond to all questions from the assessor during the assessment?*

Please explain:

Prior to this assessment did you receive a reminder call?*

If transportation services were arranged to get you to and from the assessment were they on time and courteous?*

Please explain:

If interpreter services were used during your assessment were they effective in assisting you to communicate with the assessor?*

Please explain:

Do you have any further comments regarding today’s assessment?

Do you feel that you have had adequate information provided to you to accurately conclude your assessment opinion?*

If you wish to be contacted by a member of management regarding any feedback you may have and/or to lay a formal complaint, please indicate “YES” and complete the following section: *

Date of Assessment:*

Assessor Name:*

Your Name:

Your Email:

Thank you for taking the time to complete this questionnaire.

Please submit the survey at your earliest convenience to Evolve via

E-mail: evolve@evolveax.com

Fax: 519-432-7522

Mail: 1208-383 Richmond Street, London, ON, N6A 3C4

If you wish to file a formal complaint please contact us. If a response is requested, we will respond within 7 business days of receipt.