Respite Care Needs Survey

1. In what locale do you live?

In what locale do you live? Carlisle Area

Mechanicsburg

Camp Hill

Newport

Shippensburg

Other (please specify)

2. What days of the week would respite care support your needs? (check all that apply)

What days of the week would respite care support your needs? (check all that apply) Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

3. What time of day would respite care support your needs? (check all that apply)

	Preferred Time	Alternate Preferred Time	Not Needed
Early Morning (before school/work)	*What time of day would respite care support your needs? (check all that apply) Early Morning (before school/work) Preferred Time	Early Morning (before school/work) Alternate Preferred Time	Early Morning (before school/work) Not Needed
Late Afternoon (after school/work)	Late Afternoon (after school/work) Preferred Time	Late Afternoon (after school/work) Alternate Preferred Time	Late Afternoon (after school/work) Not Needed
Weekday Evenings (6pm-10pm)	Weekday Evenings (6pm-10pm) Preferred Time	Weekday Evenings (6pm-10pm) Alternate Preferred Time	Weekday Evenings (6pm-10pm) Not Needed
Weekends Daytime	Weekends Daytime Preferred Time	Weekends Daytime Alternate Preferred Time	Weekends Daytime Not Needed
Weekend Evenings	Weekend Evenings Preferred Time	Weekend Evenings Alternate Preferred Time	Weekend Evenings Not Needed

Other (please specify)

4. What are the primary reasons you would use respite care?

What are the primary reasons you would use respite care? Provide stress relief.

Give me support needed so I can work

Help me focus on my own health care needs.

Provide a social opportunity for my loved one.

Allow time for a vacation.

Allow time to focus on other members of my family.

Help transition my student from school age to adult services.

Help transition my family member to an adult living placement, (i.e. apartment living, supported apartment living, group home).

Other (please specify)

5. What is the age range of your family member(s)?

What is the age range of your family member(s)? 0-5 years

6-13 years

14-21 years

22-30 years

31-40 years

41-50 years

51-60 years

61+ years

6. Rate the importance of the following program components.

	Extremely Important	Somewhat Important	Less Important	N/A
Staff to participant ratio	*Rate the importance of the following program components. Staff to participant ratio Extremely Important	Staff to participant ratio Somewhat Important	Staff to participant ratio Less Important	Staff to participant ratio N/A
On-site activities (participant remains on-site)	On-site activities (participant remains on-site) Extremely Important	On-site activities (participant remains on-site) Somewhat Important	On-site activities (participant remains on-site) Less Important	On-site activities (participant remains on-site) N/A
Community activities (i.e. bowling, movies)	Community activities (i.e. bowling, movies) Extremely Important	Community activities (i.e. bowling, movies) Somewhat Important	Community activities (i.e. bowling, movies) Less Important	Community activities (i.e. bowling, movies) N/A
Monthly calendar of planned activities	Monthly calendar of planned activities Extremely Important	Monthly calendar of planned activities Somewhat Important	Monthly calendar of planned activities Less Important	Monthly calendar of planned activities N/A
Behavior Support	Behavior Support Extremely Important	Behavior Support Somewhat Important	Behavior Support Less Important	Behavior Support N/A
Cost of program	Cost of program Extremely Important	Cost of program Somewhat Important	Cost of program Less Important	Cost of program N/A

Other (please specify)

7. What is your vision of a respite program? Dream Big!!

What is your vision of a respite program? Dream Big!!

8. This survey is anonymous. If you would like to provide your contact information so we can address any questions or concerns you may have, please submit with this survey.

This survey is anonymous. If you would like to provide your contact information so we can address any questions or concerns you may have, please submit with this survey.

Respite Care Needs

1. Respite Care Needs Survey

1. In what locale do you live?

2. What days of the week would respite care support your needs? (check all that apply)

3. What time of day would respite care support your needs? (check all that apply)

4. What are the primary reasons you would use respite care?

5. What is the age range of your family member(s)?

6. Rate the importance of the following program components.

7. What is your vision of a respite program? Dream Big!!

8. This survey is anonymous. If you would like to provide your contact information so we can address any questions or concerns you may have, please submit with this survey.