Survey for Providers 2015 Question Title * 1. What type of organization are you affiliated with? (check all that apply) Continuing Care Retirement Community Senior Center Home Care Agency Home Health Agency Home and Community Based Services Skilled Nursing/Rehab Center Assisted Living Community Personal Care Home Adult Day Respite Hospice Hospital Transportation Community Outreach Program Managed Care Organization Special Care/Memory Unit Retirement Community (Market Place/HUD subsidized) Other (please specify) Question Title * 2. What is your role in the organization? Executive Director/Administrator Regional Manager Nursing staff Medical Professional Other (please specify) Question Title * 3. Please specify organization type (check all that apply). For Profit Not-for-profit Part of a corporate chain Considered a faith-based organization Question Title * 4. How many workers does your organization employ? 1-5 6-10 11-20 21-50 51-75 76-100 101-150 151-200 More than 200 Don’t know Question Title * 5. In the last week, how many individuals/clients did your organization serve? 1-5 6-10 11-20 21-50 51-75 76-100 101-150 151-200 More than 200 Don’t know Question Title * 6. What percent of these individuals are living with Alzheimer’s or a related dementia? 0% 1-10% 11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-99% 100% Don’t know Next