Lifespan Respite Needs Assessment

1. Lifespan Respite Training/TA Needs

The Lifespan Respite Training and Technical Assistance Project of the ARCH National Respite Network and Resource Center would greatly appreciate your input in planning its training and TA activities. Please take a moment to respond to each question by indicating your level of need or preference in each of the following categories.

1. Indicate what you think ARCH’s priorities should be by rating the following activities (Low: lowest priority to High:Top priority):

	Low	Medium	High
Overview of Lifespan Respite Principles and Best Practices	*Indicate what you think ARCH’s priorities should be by rating the following activities (Low: lowest priority to High:Top priority): Overview of Lifespan Respite Principles and Best Practices Low	Overview of Lifespan Respite Principles and Best Practices Medium	Overview of Lifespan Respite Principles and Best Practices High
Update Federal/State Respite Funding/Eligibility Information	Update Federal/State Respite Funding/Eligibility Information Low	Update Federal/State Respite Funding/Eligibility Information Medium	Update Federal/State Respite Funding/Eligibility Information High
Update respite program guidelines	Update respite program guidelines Low	Update respite program guidelines Medium	Update respite program guidelines High
Create a compendium of respite provider training curricula	Create a compendium of respite provider training curricula Low	Create a compendium of respite provider training curricula Medium	Create a compendium of respite provider training curricula High
Assist building/maintaining statewide respite coalitions	Assist building/maintaining statewide respite coalitions Low	Assist building/maintaining statewide respite coalitions Medium	Assist building/maintaining statewide respite coalitions High
Assist with onsite training events	Assist with onsite training events Low	Assist with onsite training events Medium	Assist with onsite training events High
Respite as an abuse/neglect prevention strategy	Respite as an abuse/neglect prevention strategy Low	Respite as an abuse/neglect prevention strategy Medium	Respite as an abuse/neglect prevention strategy High

Other Areas of Interest

2. Please indicate your level of need for training/technical assistance in the following area -- Respite for Special Populations including [from Low (lowest need) to High (highest need)]:

Other Special Populations

3. Please indicate your level of need for training/technical assistance in the following area -- Respite Service Delivery Models [from Low (lowest need) to High (highest need)]:

	Low	Medium	High
Respite Definitions	*Please indicate your level of need for training/technical assistance in the following area -- Respite Service Delivery Models [from Low (lowest need) to High (highest need)]: Respite Definitions Low	Respite Definitions Medium	Respite Definitions High
Emergency or Crisis Respite	Emergency or Crisis Respite Low	Emergency or Crisis Respite Medium	Emergency or Crisis Respite High
In-home models	In-home models Low	In-home models Medium	In-home models High
Out-of-home models	Out-of-home models Low	Out-of-home models Medium	Out-of-home models High
Overnight, weekend, extended	Overnight, weekend, extended Low	Overnight, weekend, extended Medium	Overnight, weekend, extended High
Volunteer	Volunteer Low	Volunteer Medium	Volunteer High
Faith-based	Faith-based Low	Faith-based Medium	Faith-based High
Consumer-Directed	Consumer-Directed Low	Consumer-Directed Medium	Consumer-Directed High

Other (please specify)

4. Please indicate your level of need for training/TA in the following administrative/program implementation areas:

	Low	Medium	High
Overview of Best Practices in Lifespan Respite	*Please indicate your level of need for training/TA in the following administrative/program implementation areas: Overview of Best Practices in Lifespan Respite Low	Overview of Best Practices in Lifespan Respite Medium	Overview of Best Practices in Lifespan Respite High
Identifying Respite Partners	Identifying Respite Partners Low	Identifying Respite Partners Medium	Identifying Respite Partners High
Effective use of vouchers	Effective use of vouchers Low	Effective use of vouchers Medium	Effective use of vouchers High
Outcome-based Evaluation	Outcome-based Evaluation Low	Outcome-based Evaluation Medium	Outcome-based Evaluation High
Strategies for collaboration	Strategies for collaboration Low	Strategies for collaboration Medium	Strategies for collaboration High
Risk Management	Risk Management Low	Risk Management Medium	Risk Management High
Staff recruitment and retention	Staff recruitment and retention Low	Staff recruitment and retention Medium	Staff recruitment and retention High
Marketing and Public Awareness	Marketing and Public Awareness Low	Marketing and Public Awareness Medium	Marketing and Public Awareness High
Quality assurance	Quality assurance Low	Quality assurance Medium	Quality assurance High
Needs Assessments	Needs Assessments Low	Needs Assessments Medium	Needs Assessments High
Respite Registries/Statewide Data Systems	Respite Registries/Statewide Data Systems Low	Respite Registries/Statewide Data Systems Medium	Respite Registries/Statewide Data Systems High

Other administrative or program development, implementation, or management training/TA needs

5. Please indicate your preference for the following training/tech. assistance formats (Low: limited interest to High: most preferred)

	Low	Medium	High
Live Webinars	*Please indicate your preference for the following training/tech. assistance formats (Low: limited interest to High: most preferred) Live Webinars Low	Live Webinars Medium	Live Webinars High
Archived Webinars	Archived Webinars Low	Archived Webinars Medium	Archived Webinars High
Fact Sheets	Fact Sheets Low	Fact Sheets Medium	Fact Sheets High
Guidebooks/Manuals	Guidebooks/Manuals Low	Guidebooks/Manuals Medium	Guidebooks/Manuals High
Issue Briefs	Issue Briefs Low	Issue Briefs Medium	Issue Briefs High
Conference Calls	Conference Calls Low	Conference Calls Medium	Conference Calls High
List serves	List serves Low	List serves Medium	List serves High
Web-based Discussion Forums	Web-based Discussion Forums Low	Web-based Discussion Forums Medium	Web-based Discussion Forums High
Regular newsletters	Regular newsletters Low	Regular newsletters Medium	Regular newsletters High
Blogs	Blogs Low	Blogs Medium	Blogs High
Facebook	Facebook Low	Facebook Medium	Facebook High
On-site State Visits	On-site State Visits Low	On-site State Visits Medium	On-site State Visits High
Conferences/Meetings (National/Regional)	Conferences/Meetings (National/Regional) Low	Conferences/Meetings (National/Regional) Medium	Conferences/Meetings (National/Regional) High
Email or individual phone consultation	Email or individual phone consultation Low	Email or individual phone consultation Medium	Email or individual phone consultation High

Other Preferred Formats

6. Additional Comments:

Additional Comments:

7. Please tell us what state you are from. This helps us better direct our training and TA resources. If you would like to provide your name and contact information, please do so, but it is not required.

Please tell us what state you are from. This helps us better direct our training and TA resources. If you would like to provide your name and contact information, please do so, but it is not required. Name:
Agency/Organization:
Address:
City/Town:
State:
ZIP/Postal Code:
Country:
Email Address:
Phone Number:

8. Do you represent a (please check all that apply):

Do you represent a (please check all that apply): State or local government agency

Private State Advocacy or Service Organization

State Respite Coalition

Community-based program or agency

Faith-based program or agency

Respite Provider (non-profit)

Respite Provider (for-profit)

Other

9. If you checked "Other"in the previous questions, please describe:

If you checked "Other"in the previous questions, please describe:

10. What ages and types of disabilities or chronic conditions do you serve?

	0 to 18 or 21	18 or 21 to 49	50 to 59	60 to 75	76 or older
Developmental Disabilities	*What ages and types of disabilities or chronic conditions do you serve? Developmental Disabilities 0 to 18 or 21	Developmental Disabilities 18 or 21 to 49	Developmental Disabilities 50 to 59	Developmental Disabilities 60 to 75	Developmental Disabilities 76 or older
Mental Health Conditions	Mental Health Conditions 0 to 18 or 21	Mental Health Conditions 18 or 21 to 49	Mental Health Conditions 50 to 59	Mental Health Conditions 60 to 75	Mental Health Conditions 76 or older
Alzheimer's or other Neurological Conditions	Alzheimer's or other Neurological Conditions 0 to 18 or 21	Alzheimer's or other Neurological Conditions 18 or 21 to 49	Alzheimer's or other Neurological Conditions 50 to 59	Alzheimer's or other Neurological Conditions 60 to 75	Alzheimer's or other Neurological Conditions 76 or older
Physical Disabilities	Physical Disabilities 0 to 18 or 21	Physical Disabilities 18 or 21 to 49	Physical Disabilities 50 to 59	Physical Disabilities 60 to 75	Physical Disabilities 76 or older
Autism	Autism 0 to 18 or 21	Autism 18 or 21 to 49	Autism 50 to 59	Autism 60 to 75	Autism 76 or older
AIDS/HIV	AIDS/HIV 0 to 18 or 21	AIDS/HIV 18 or 21 to 49	AIDS/HIV 50 to 59	AIDS/HIV 60 to 75	AIDS/HIV 76 or older
Frail Elderly	Frail Elderly 0 to 18 or 21	Frail Elderly 18 or 21 to 49	Frail Elderly 50 to 59	Frail Elderly 60 to 75	Frail Elderly 76 or older
Brain Injury	Brain Injury 0 to 18 or 21	Brain Injury 18 or 21 to 49	Brain Injury 50 to 59	Brain Injury 60 to 75	Brain Injury 76 or older
Cognitive Impairment	Cognitive Impairment 0 to 18 or 21	Cognitive Impairment 18 or 21 to 49	Cognitive Impairment 50 to 59	Cognitive Impairment 60 to 75	Cognitive Impairment 76 or older
Spinal Cord Injury	Spinal Cord Injury 0 to 18 or 21	Spinal Cord Injury 18 or 21 to 49	Spinal Cord Injury 50 to 59	Spinal Cord Injury 60 to 75	Spinal Cord Injury 76 or older
Epilepsy	Epilepsy 0 to 18 or 21	Epilepsy 18 or 21 to 49	Epilepsy 50 to 59	Epilepsy 60 to 75	Epilepsy 76 or older
Chronic Conditions such as MS or ALS	Chronic Conditions such as MS or ALS 0 to 18 or 21	Chronic Conditions such as MS or ALS 18 or 21 to 49	Chronic Conditions such as MS or ALS 50 to 59	Chronic Conditions such as MS or ALS 60 to 75	Chronic Conditions such as MS or ALS 76 or older
Other Chronic Illness/Stroke	Other Chronic Illness/Stroke 0 to 18 or 21	Other Chronic Illness/Stroke 18 or 21 to 49	Other Chronic Illness/Stroke 50 to 59	Other Chronic Illness/Stroke 60 to 75	Other Chronic Illness/Stroke 76 or older
Other	Other 0 to 18 or 21	Other 18 or 21 to 49	Other 50 to 59	Other 60 to 75	Other 76 or older

11. Are you a family caregiver?

Are you a family caregiver? YES

12. If you checked yes to the question, "Are you a family caregiver?" what is the age of the person you are caring for? If you are caring for more than one person, please check as many as appy.

If you checked yes to the question, "Are you a family caregiver?" what is the age of the person you are caring for? If you are caring for more than one person, please check as many as appy. 0-18 or 21

21 to 49

49-59

60-75

76 or older

Thank you so much for taking the time to complete this survey.

ARCH National Respite Network and Resource Center is a non-profit membership organization seeking to provide, promote and enhance respite services for all family caregivers caring for loved ones of all ages and disabling and chronic conditions. The Lifespan Respite Training/TA Center is funded in part by the US Administration on Aging in partnership with the Family Caregiver Alliance and its Technical Assistance Center on Caregiver Programs. If you need more information, please contact Jill Kagan or Maggie Edgar at ARCH or visit the ARCH website at www.archrespite.org.

Email: jbkagan@verizon.net
Phone: 703-256-2084
or
Email: edgar@zipcon.net
Phone: 206-632-5208

December 2009

This project is supported, in part, under a grant from the U.S. Department of Health and Human Services, Administration on Aging. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. These contents, however, do not necessarily represent the policy of the U.S. Department of Health and Human Services and endorsement by the Federal Government should not be assumed

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	Low	Medium	High
Children/teens	*Please indicate your level of need for training/technical assistance in the following area -- Respite for Special Populations including [from Low (lowest need) to High (highest need)]: Children/teens Low	Children/teens Medium	Children/teens High
Culturally/linguistically diverse populations	Culturally/linguistically diverse populations Low	Culturally/linguistically diverse populations Medium	Culturally/linguistically diverse populations High
Children who are medically fragile	Children who are medically fragile Low	Children who are medically fragile Medium	Children who are medically fragile High
Children/Teens with emotional/behavioral disorders	Children/Teens with emotional/behavioral disorders Low	Children/Teens with emotional/behavioral disorders Medium	Children/Teens with emotional/behavioral disorders High
Adults with emotional/behavioral disorders	Adults with emotional/behavioral disorders Low	Adults with emotional/behavioral disorders Medium	Adults with emotional/behavioral disorders High
Children/adults with autism	Children/adults with autism Low	Children/adults with autism Medium	Children/adults with autism High
Aging family member or friend	Aging family member or friend Low	Aging family member or friend Medium	Aging family member or friend High
Adults with Alzheimer’s/dementia	Adults with Alzheimer’s/dementia Low	Adults with Alzheimer’s/dementia Medium	Adults with Alzheimer’s/dementia High
Individuals with brain injury	Individuals with brain injury Low	Individuals with brain injury Medium	Individuals with brain injury High
Individuals with spinal cord injury	Individuals with spinal cord injury Low	Individuals with spinal cord injury Medium	Individuals with spinal cord injury High
Children/Adults with developmental disabilities	Children/Adults with developmental disabilities Low	Children/Adults with developmental disabilities Medium	Children/Adults with developmental disabilities High
Adults with neurological conditions (ALS, MS, etc)	Adults with neurological conditions (ALS, MS, etc) Low	Adults with neurological conditions (ALS, MS, etc) Medium	Adults with neurological conditions (ALS, MS, etc) High
Grandparents/other relatives caring for children	Grandparents/other relatives caring for children Low	Grandparents/other relatives caring for children Medium	Grandparents/other relatives caring for children High
Individuals living in rural areas	Individuals living in rural areas Low	Individuals living in rural areas Medium	Individuals living in rural areas High
Foster Parents	Foster Parents Low	Foster Parents Medium	Foster Parents High