Foundation for the Developmentally Disabled, Inc. Respite Care Initiative

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1. As the caregiver, do you currently use a respite provider?

As the caregiver, do you currently use a respite provider?   Yes, and I am happy with our current arrangement. Yes, and I am unhappy with our current arrangement. No, but we would be interested in using such a service. No, and we would not be interested in using such a service.

2. If you are not currently using respite services, why not? Please, mark your top two reasons.

If you are not currently using respite services, why not? Please, mark your top two reasons.   Financial Considerations Liability concerns Need a list of trust caregivers Not sure what to expect/where to begin

Other Our prior experiences were unpleasant Uncomfortable with alternate care givers

3. I would like the Foundation For Developmentally Disabled to try and help me with respite in the following ways:

I would like the Foundation For Developmentally Disabled to try and help me with respite in the following ways:   I do not feel I need help in this area Preparing a list of available care givers for short periods of time (Hours) Preparing a list of available providers for longer periods of time (Days) Preparing a list of available providers that would come to my home

Preparing a list of available providers that take the member to a respite home Assisting in researching and checking into providers Assisting in the researching and checking into financial considerations Forming and performing respite services

4. How frequently do you use or would you use a respite provider?

How frequently do you use or would you use a respite provider?   Very Frequently - Weekly to Several Times a Month Frequently - Once a month Some what frequently - Every few months Rarely - Once or twice a year

5. As the caregiver, do you have emergency plans for caring for the member if you are unable to do so?

As the caregiver, do you have emergency plans for caring for the member if you are unable to do so?   Yes No

6. Does the member receive or participate in any of the following benefits or programs? Select all that apply.

Does the member receive or participate in any of the following benefits or programs? Select all that apply.   Social Security Income Social Security Disability Income Med Waiver

Public Transportation Private Transportation Day Training

7. In regards to the members level of care required for the following areas please mark the description that most accurately reflects their current needs.

	No assistance or reminder needed	Reminder needed	Some assistance needed	Total assistance needed
Bathing	*In regards to the members level of care required for the following areas please mark the description that most accurately reflects their current needs. Bathing No assistance or reminder needed	Bathing Reminder needed	Bathing Some assistance needed	Bathing Total assistance needed
Cooking	Cooking No assistance or reminder needed	Cooking Reminder needed	Cooking Some assistance needed	Cooking Total assistance needed
Grooming	Grooming No assistance or reminder needed	Grooming Reminder needed	Grooming Some assistance needed	Grooming Total assistance needed
Household chores/Cleaning	Household chores/Cleaning No assistance or reminder needed	Household chores/Cleaning Reminder needed	Household chores/Cleaning Some assistance needed	Household chores/Cleaning Total assistance needed
Medications	Medications No assistance or reminder needed	Medications Reminder needed	Medications Some assistance needed	Medications Total assistance needed
Toileting	Toileting No assistance or reminder needed	Toileting Reminder needed	Toileting Some assistance needed	Toileting Total assistance needed

8. Does the member live in Collier or Lee Counties?

Does the member live in Collier or Lee Counties?   Yes, Annually

Yes, Seasonally

No

9. Are you a member of the Foundation For Developmentally Disabled?

Are you a member of the Foundation For Developmentally Disabled?   Yes Not, yet, but I would like to be. No

10. Contact information (optional) if you wish to be available for follow up questions or receive results of this survey please complete.

Contact information (optional) if you wish to be available for follow up questions or receive results of this survey please complete.   Name:
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