New FMP New Family Model Provider Questionnaire Please all questions below. OK Question Title * 1. Please complete contact information. Name * Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Email Address * Phone Number * OK Question Title * 2. Why are you interested in providing supports for the elderly and/or persons with disabilities? OK Question Title * 3. What qualities do you have that you feel would make you a good caregiver? OK Question Title * 4. What do you consider to be the most challenging aspect of supporting a person? OK Question Title * 5. What type of daily activities would you plan for a person you supported? OK Question Title * 6. Are you able to assist with lifting and transferring for a person with mobility issues? Yes No OK Question Title * 7. Are you comfortable supporting a person who may need total assistance with hygiene, bathing, dressing, oral care, etc? Yes No OK Question Title * 8. How did you hear about us? OK Question Title * 9. All Family Model Providers are required to have a back-up person on file. Please provide us with your back-up person's contact information. Name Email Address Phone Number OK Question Title * 10. What time of day would be most convenient for you for someone from Group Effort to contact you for a short phone interview in the next 48 hrs? 9 am - 11 am 2 pm - 4 pm 5 pm or later OK SUBMIT
