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Satisfaction with ARCH National Respite Locator Immediate
Thank you for using the online ARCH National Respite Locator Service to search for respite providers or programs and/or for additional respite resources. We would very much appreciate it if you could take just a minute to respond to this short survey. It will help us make the respite locator more responsive to your needs.
1.
How useful was the Respite Locator Service overall?
Extremely useful
Very useful
Useful
Somewhat useful
Not at all useful
2.
Please indicate which categories of information were useful?
Respite Provider Lists
Medicaid Waivers
Other Public Funding Sources
General Caregiving Resources
State Contacts for More Information
What other information would you like to see included in the Respite Locator Service?
3.
How user-friendly is the online Respite Locator Service?
Extremely user-friendly
Very user-friendly
User-friendly
Somewhat user-friendly
Not at all user-friendly
4.
How many times have you used the National Respite Locator Service
This is the first time
2-4 times
More than 4 times
5.
How likely are you to use the Respite Locator Service again?
Extremely likely
Very likely
Likely
Somewhat likely
Not at all likely
6.
How likely are you to recommend the Respite Locator Service to others?
Extremely likely
Very likely
Likely
Somewhat likely
Not at all likely
7.
Are you a:
Family Caregiver
Care Recipient
Other family member
Neighbor or Friend
Other (please specify)
8.
If you are not seeking respite for yourself, are you seeking respite information as a representative of:
Respite Provider
Lifespan Respite Program
State Government Agency
Local Government Agency
Aging and Disability Resource Center
State Respite Coalition
Caregiver Coalition
National Organization
Private State disability or aging organization
Community-based organization
Faith-based organization
Private insurance company
Hospital or health care facility
Veterans Affairs Caregiver Program
Other (please specify)
9.
Please provide any additional feedback.
*
10.
Please let us know which city and state you are from. The remaining contact information is optional. If you would like us to get back to you to provide assistance, please provide your email address.
(Required.)
Name:
Company:
Address:
Address 2:
City/Town:
*
State:
*
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
Country:
Email Address:
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