Connecticut Lifespan Respite Coalition: 2011 Respite Provider Survey
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1. PLEASE COMPLETE THIS SURVEY! YOUR TIME AND EFFORT ARE VERY MUCH APPRECIATED!

 
The CT Lifespan Respite Coalition (CLRC), in conjunction with the CT Department of Social Services (DSS), is conducting this survey among public and private AGENCIES/SERVICE ORGANIZATIONS (A/SO)to obtain vital descriptive information for consumers of respite care. It is intended this data, gathered from formal and informal (grassroot)provider groups, will provide anecdotal information (e.g. fee structure,payment options) not routinely available,yet so important to consumers when they are exploring all options for respite care.

! YOUR PARTICIPATION IS CRITICAL !

...Afterall, your program might be just what a family is looking for. Please, take 20 minutes to complete 25 multiple choice questions OR call Peaches Quinn, CLRC Project Administrator, (860) 247-2572, to complete the survey by phone. Please respond TODAY. Following data analysis, we will send you a copy of the results.

On behalf of CLRC, DSS and so many families and caregivers who give nonstop love and caring to persons in need... Thank you!

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1. Respite Care Agency/Service Organization (A/SO) information:

2. Which of the following describes your respite care A/SO?

3. Do you represent any of the following?

4. Are you

5. For what time period does your A/SO provide respite care? (Check all that apply)

6. How often will you provide respite care to the same client?

7. Which age groups do you serve? (check all that apply)

8. What populations can use your respite services? (Check all that apply)

9. Do you provide respite care in medical homes?

10. How are your A/SO's fees for respite subsidized? (check all that apply)

11. What is your charging structure? (check all that apply)

12. Are the fees for your respite services covered by (check all that apply):

13. What forms of payment will your A/SO accept from the family?

14. Do you offer a sliding scale for respite charges (based on income)?

15. Who pays the caregiver?

16. What requirements must clients meet to be eligible for your respite care services? (check all that apply)

17. What intake procedures are REQUIRED in order to receive respite services? (check all that apply)

18. Do you sometimes have a waiting list of clients in need of respite care?

19. Can your A/SO accommodate foreign speaking clients?

20. Do you require caregivers to attend respite care training/continuing ed sessions (whether they are volunteer or paid)

21. Do you produce background checks on every caregiver you send to a home?

22. If you are a provider of respite care, have you been formally trained?

23. Would you send your respite care workers to a statewide training program?

24. Please indicate training topics that you believe should be included in ANY training program for respite care workers.

25. Please indicate training topics you cover in YOUR training program for respite care workers.

26. What do you believe are current unmet needs in respite care? (check all that apply)

27. Do you want your service or agency listed on the Connecticut Lifespan Respite Coalition Database and Resource List?

28. If you answered yes to the previous question, please note any additional information regarding your A/SO's respite program, eligibility criteria, and cost information you'd like CLRC to publish:

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