Participation in Triple-R During Modified Services

Triple-R is currently offering service with a reduced schedule and abiding by strict protocol to reduce the risk of COVID-19. All sites are currently open from 9:00am-2:00pm, days of service vary per site. Please fill out the survey below and we will be happy to get in touch with you soon.

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* 1. What is your name? (Caregiver)

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* 2. What is the name of the older adult who would attend Triple-R?

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* 3. Please provide your phone number

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* 4. Please provide your email address

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* 5. What is your preferred method of communication?

Phone

Text

Zoom meeting

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* 6. What is your main interest(s) for your loved one participating in Triple-R? (check all that apply)

You need a regular break from your caregiving duties to maintain your own health

Your loved one is bored at home and needs social stimulation

You are noticing physical or cognitive decline in your loved one and would like to maintain his/her/their abilities to the greatest extent possible

You need a fun and supervised place for your loved one to go while you go to work

Other (please specify)

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* 7. During modified services, older adults participating in the program will need to maintain physical distancing and wear a mask regardless of vaccination status. Please check if your loved one:

Can wear a mask, with the exception of drinking or eating

Can respond to verbal cues from staff for instructions or redirection (as opposed to needing physical assistance)

Requires less than 15 minutes of close physical assistance when using restroom

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* 8. We may still be able to provide care during modified service even if you cannot check all of the boxes above. To better understand your loved ones needs, please explain what assistance or accomodation you feel your loved one may need to attend the program during modified service.

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* 9. Has your loved one been vaccinated for coronavirus? (Information will remain confidential)

Yes, first dose complete but not second dose

Yes, loved one has received both doses

No, but intend to get vaccinated before attending Triple-R

No, do not intend to be vaccinated

Do not want to answer

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* 10. Based on the questions above, how would you like to proceed?

I will wait for Regular Services (longer day and more personal care)

I would like to sign my loved one up for Modified Services (4 hour day and limited personal care)

I would like to be taken off the waiting list

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* 11. If you have any questions or concerns, please let us know and we will get back to you. Once you have submitted this survey, a Triple-R Coordinator will get in touch with you within 2 business days.

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* 12. What site are you most interested in attending?

Midtown Site (located in the Hart Senior Center at 27th & J Streets)

North Sacramento (located on the Woodlake Elementary School Campus)

South Land Park (located in South Hills Shopping Center)