Introduction

Evaluation of the Lifespan Respite Care Program

Caregivers are invited to complete a survey that will enable the Alabama Department of Senior Services and Alabama Lifespan Respite Network to learn about caregiver support services in Alabama. The purpose of the survey is to learn more about the availability and capacity of caregiver support services in Alabama for serving informal and unpaid caregivers. The information you provide will be used to plan improvements to lifespan respite services for caregivers of people with disabilities and chronic illness. 
 
We will NOT collect your name or Email address without your permission. Your personal identity will not be revealed to others. It will require about 20 minutes to reply to the survey. You may refuse to answer any question or discontinue participation at any time without penalty. Responses will be automatically submitted to this online survey.
 
You will not receive any special consideration if you take part in this assessment. If you have questions about your rights as a participant, or concerns or complaints about this activity, you may contact Mrs. Traci Dunklin, Alabama Department of Senior Services, State Director of the Alabama Caregiver Program. Mrs. Dunklin may be reached at 1-800-243-5463 or 1-800 Age Line.
Please tell us about yourself.

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* 1. What is your zip code?

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* 2. What is your race or ethnic group? (Select all that apply)

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* 3. What is your gender?

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* 4. What is your age in years? (Enter a whole number, e.g. 45)

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* 5. What is your marital status? (Select one response)

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* 6. In what range is your annual family income? (Select one response)

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* 7. How many people who live in your home have a disability or chronic illness requiring daily assistance?

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* 8. Which best describes your relationship to the person with a disability or chronic illness? (Select all that apply)

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* 9. Do you receive a Medicaid waiver for caregiver respite services?

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* 10. How often do you access caregiver respite services using your Medicaid waiver?

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* 11. How do you expect respite services to help you as a caregiver?

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* 12. What event(s) led you to seek respite services most recently? (Select all that apply)

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* 13. Tell how members of your household were affected by the event(s):

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* 14. The most recent time I applied for caregiver respite services: (Select all that apply)

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* 15. What agency or organization most recently provided caregiver respite services to you?

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* 16. The most recent time I received caregiver respite services, it lasted:

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* 17. Was the length of time you received caregiver respite services enough?

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* 18. How would you feel if caregiver respite services were not available?

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* 19. In your experience, how true is each statement about respite services?

  Very True Somewhat True Not at all True Does Not Apply
Trained respite staff met caregiving needs.
Respite offered a short-term break from caregiving.
Respite reduced the risk of neglect or mistreatment.
Respite provided safe and secure care.
Respite enabled me to focus on needs of others in my household.
Respite allowed me to enjoy social and recreational activities.
Respite reduced my stress level as a caregiver.
Respite increased my ability to effectively provide care.
The person for whom I provide care felt positively about respite.
Tell us about your experience.

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* 20. How many times have you been unable to find caregiver respite services when you needed them?

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* 21. Consider your most recent experience with caregiver respite services. How long did you have to wait for respite services?

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* 22. Are you on a waiting list for caregiver respite services?

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* 23. How did you learn about respite services in your community? (Select all that apply)

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* 24. Which agencies or organizations helped you find respite services as a caregiver? (Select all that apply)

Please tell us about the person for whom you MOST RECENTLY received respite services as a caregiver.

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* 25. What is the gender of the person with a disability or chronic illness who requires daily care?

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* 26. What is the age in years of the person with a disability or chronic illness who requires daily care?

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* 27. How much assistance does the person with a disability or chronic illness require?

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* 28. How much difficulty does the person with a disability or chronic illness have with each of the following?

  No difficulty Some difficulty Much difficulty Don't know/Does not apply
Communication (e.g. speaking, hearing)
Feeding
Dressing
Bathing and hand washing
Caring for mouth and teeth
Toileting
Cooking
Taking medication as prescribed
Transportation (driving, riding a bus)
Thank you for your time and effort! Please answer these final questions. 

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* 29. What are your additional comments about caregiver respite services?

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* 30. Would you like to receive a summary of the survey results? If so, please provide the following mailing information. 

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* 31. May we contact you again to request additional information?

0 of 31 answered
 

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