Phased Repoening Survey for Caregivers (Post COVID-19 shelter at home)

Empower Cherokee Phased Reopening Survey

This survey is intended to help us plan for the reopening of our organization. We will be doing so in accordance with Governor Kemp's guidelines as well as those put out by DBHDD. This survey does not guarantee any promises about when we open, what days participants will attend, what location they will attend, or exactly what measures will be put into place. Instead, however, this survey will give us a baseline for planning. As we consider reopening we want to take into account everyone's perspective and reopen in a safe manner to reduce risk of spreading COVID-19 as much as possible.

Thank you in advance for your careful responses. I truly hope we will be able to see everyone again very soon.

Question Title

* 1. It is important you share contact information so that we can plan for attendance patterns.

Name

Name of Person(s) in your care (first name last initial)

City/Town

Email Address

Phone Number

Question Title

* 2. If Empower Cherokee were to reopen with social distancing and safety guidelines in place would you be interested in returning to the program? (If your answer is no you can skip the remainder of the questions).

Yes

No (If your answer is no please give the reason why so we can plan for your needs)

Question Title

* 3. If Empower Cherokee were to stay open but CATS did not run would you be able to drop off and pick up your loved one during regular business hours?

Yes

Question Title

* 4. If the participant in your care attended our program can you guarantee that you or someone who provides you with assistance will be available at all times to pick up the participant in the event they present with COVID-19 symptoms?

Yes someone can be available and within the county to pick up in 30 min or less.

Yes someone can be reached but it could take up to an hour or more to pick up

No we cannot guarantee someone would be available

Question Title

* 5. Would the participant in your care be willing/able to safely and appropriately wear a mask during program hours?

Yes Independently

Yes with Verbal Reminders

Yes with Some Physical Assistance

No Not Consistently

No It would not be safe for them to try due to health and mobility issues.

Question Title

* 6. Would the participant in your care be able to understand/comply with the 6-foot social distancing?

Yes Independently

Yes with Verbal Reminders

Yes with Physical Assistance

Not with Consistancy

Question Title

* 7. Would the participant in your care be able to maintain sanitary conditions for themselves and in their personal space? (Hand washing, sanitizing personal items, tabletops chairs, etc. )

Yes Independently

Yes with Verbal Reminders

Yes with Physical Assistance

Not Consistently

Question Title

* 8. Would the participant in your care be willing to refrain from bringing items such as bags, purses, and other items that cannot be easily sanitized?

Yes

Question Title

* 9. Would you be willing to send a fully disposable lunch inclusive of all napkins, utensils, plates, drinks, etc. that the participant would need?

Yes - I will send a lunch that has everything the participant in my care needs and does not require a microwave or items to be sent back home.

No - I am unable to make this accommodation. (please explain why.)

Question Title

* 10. During the initial phase of reopening we will be on an alternating schedule. What would the preference of the participant in your care?

(note your answer does not guarantee you that schedule)

Monday and Wednesday

Tuesday and Thursday

The participant in my care will only come back when their full pre COVID-19 schedule can be accomodated.

Question Title

* 11. It may be necessary to temporarily relocate staff and participants across all of our buildings to maximize social distancing. Is the participant in your care willing to participate at any of our service locations (Main Campus, Tanner Building, Eagle Point).

Yes any location is fine

Only Main Campus - both Main Campus Building and Tanner Building are fine

Only the Main Campus Buidling

Only Eagle Point

Only Community Based Services

Other (please specify)

Phased Repoening Survey for Caregivers (Post COVID-19 shelter at home)

Empower Cherokee Phased Reopening Survey

Question Title

* 1. It is important you share contact information so that we can plan for attendance patterns.

Question Title

* 2. If Empower Cherokee were to reopen with social distancing and safety guidelines in place would you be interested in returning to the program? (If your answer is no you can skip the remainder of the questions).

Question Title

* 3. If Empower Cherokee were to stay open but CATS did not run would you be able to drop off and pick up your loved one during regular business hours?

Question Title

* 4. If the participant in your care attended our program can you guarantee that you or someone who provides you with assistance will be available at all times to pick up the participant in the event they present with COVID-19 symptoms?

Question Title

* 5. Would the participant in your care be willing/able to safely and appropriately wear a mask during program hours?

Question Title

* 6. Would the participant in your care be able to understand/comply with the 6-foot social distancing?

Question Title

* 7. Would the participant in your care be able to maintain sanitary conditions for themselves and in their personal space? (Hand washing, sanitizing personal items, tabletops chairs, etc. )

Question Title

* 8. Would the participant in your care be willing to refrain from bringing items such as bags, purses, and other items that cannot be easily sanitized?

Question Title

* 9. Would you be willing to send a fully disposable lunch inclusive of all napkins, utensils, plates, drinks, etc. that the participant would need?

Question Title

* 10. During the initial phase of reopening we will be on an alternating schedule. What would the preference of the participant in your care?(note your answer does not guarantee you that schedule)

Question Title

* 11. It may be necessary to temporarily relocate staff and participants across all of our buildings to maximize social distancing. Is the participant in your care willing to participate at any of our service locations (Main Campus, Tanner Building, Eagle Point).

Question Title

* 12. Please share any other comments about this topic you determine might be important.

* 10. During the initial phase of reopening we will be on an alternating schedule. What would the preference of the participant in your care?

(note your answer does not guarantee you that schedule)