Name: 

Phone Number:        Email Address: 

Date of Referral (or close estimate):           

Agency Referred to:

How were you referred to this agency? Via Phone (by calling the Volunteer Center) Via Internet (1-800-Volunteer.org)

Did you contact this agency?  --- Yes No                Did the agency contact you? --- Yes No

 If for whatever reason this referral did not work for you, please let us know so that we can assist you in finding another opportunity that will be a better fit. Please tell us why this referral did not work and what you are currently looking for.

How promptly did the agency respond to your inquiry?  --- Less than 1 day 1-3 Days 4-7 Days 7 or more days Still waiting

Were you asked to come in for an interview or training? --- Yes No

Have you since gone in for an interview or training?  --- Yes No

Have you since volunteered with this organization?  --- Yes No

 How many hours have you put in? (Total estimate)

 How frequently do you or do you plan volunteering with this group?  --- One Time Event Once a Month Every other Week Once a Week More than once a week Other

                If "Other" was selected please elaborate: 

What are your specific duties? 

Please rate the following on a scale from 1-5 with 5 being “Very Satisfied”

1.  Your enjoyment of the placement:  --- 5 - Very Satisfied 4. Satisfied 3. Neither Satisfied Nor Dissatisfied 2. Somewhat Dissatisfied 1. Very Dissatisified

 2.  Your experience with The Volunteer Center in referring you to volunteer opportunities --- 5 - Very Satisfied 4. Satisfied 3. Neither Satisfied Nor Dissatisfied 2. Somewhat Dissatisfied 1. Very Dissatisified

 3.  Your experience with the agency’s staff and volunteers? --- 5 - Very Satisfied 4. Satisfied 3. Neither Satisfied Nor Dissatisfied 2. Somewhat Dissatisfied 1. Very Dissatisified

Do you have any suggestions on how the referral process could be improved?

 Is there anything we can do now to further assist your pursuit of volunteerism? 

Have you had a great experience volunteering and would like to share your story with us in the hope that it will motivate someone else to volunteer? If so, please tell us about your experience.