South Dakota Lifespan Respite Survey

The South Dakota Respite Coalition is gathering information on respite through this survey to improve access to respite by South Dakota caregivers. This survey is to learn more about your experience as a caregiver with respite. In order to really gauge the need for respite for families across the state, we would like to hear from a variety of caregivers- from parents of children with special needs to adult children caring for their aging parents, and more. Your answers will be kept private and your name will not be on the survey. This survey is optional which means that it is your decision whether or not you want to complete.

Lifespan Respite is temporary or short-term care of a person of any age provided by an individual other than    the person’s usual or primary caregiver.  Respite is time away (a short break) for the primary caregiver who has the daily responsibilities of caregiving.

Directions:  Please respond to the following questions which best describe your situation and experience. Complete a separate survey for each person in your household who relies on you as their primary caregiver due to disability, chronic medical condition (e.g., Rheumatoid Arthritis, Cancer, COPD, Heart Disease, Parkinson’s Disease, etc.) or due to aging or primary diagnosis (e.g., ALS, Alzheimer’s, Autism, Brain Injury, Cerebral Palsy, Dementia, Developmental Disability, Epilepsy, Huntington’s Disease, Mental Health, Multiple Sclerosis, Paraplegia, Stroke, etc.).

Do you currently receive respite? (Mark one.)

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* 1. Do you currently receive respite? (Mark one.)

If yes, how many hours of respite do you use to allow yourself time away from caregiving?  (Mark all that apply.)

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* 2. If yes, how many hours of respite do you use to allow yourself time away from caregiving?  (Mark all that apply.)

Who provides you with time away from caregiving (respite)?  (Mark all that apply.)

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* 3. Who provides you with time away from caregiving (respite)?  (Mark all that apply.)

What is the payment source for the respite you (caregiver) receive? (Mark all that apply.)

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* 4. What is the payment source for the respite you (caregiver) receive? (Mark all that apply.)

Is the amount of respite you receive meeting your needs for time away from caregiving?  (Mark one.)

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* 5. Is the amount of respite you receive meeting your needs for time away from caregiving?  (Mark one.)

How did you learn about respite?  (Mark all that apply.)

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* 6. How did you learn about respite?  (Mark all that apply.)

How many hours of respite would you need to provide you with time away from caregiving? (Mark all that apply.)

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* 7. How many hours of respite would you need to provide you with time away from caregiving? (Mark all that apply.)

Barriers to receiving respite care? (Mark all that apply.)

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* 8. Barriers to receiving respite care? (Mark all that apply.)

How would or how does respite enable you to continue to be a caregiver?

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* 9. How would or how does respite enable you to continue to be a caregiver?

If you had access to employ individual respite providers (or additional providers) would that increase your ability to continue to be a caregiver? (Mark one.)

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* 10. If you had access to employ individual respite providers (or additional providers) would that increase your ability to continue to be a caregiver? (Mark one.)

Would you use a directory of respite providers (e.g., individual, agency, nursing home) if it were available? (Mark one.)

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* 11. Would you use a directory of respite providers (e.g., individual, agency, nursing home) if it were available? (Mark one.)

What do you need that will help you continue to be a caregiver?

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* 12. What do you need that will help you continue to be a caregiver?

In addition to “Caregiver” which term best describes your relationship to the person (care recipient) for whom you are the primary caregiver? (Mark one.)

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* 13. In addition to “Caregiver” which term best describes your relationship to the person (care recipient) for whom you are the primary caregiver? (Mark one.)

What is the age of the person (care recipient) for whom you are the primary caregiver?

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* 14. What is the age of the person (care recipient) for whom you are the primary caregiver?

Please check all of the following that apply to the person (care recipient) for whom you are the primary caregiver.

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* 15. Please check all of the following that apply to the person (care recipient) for whom you are the primary caregiver.

What is the county and zip code where you live? County

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* 16. What is the county and zip code where you live? County

What is your race/ethnicity? (Mark one.)

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* 17. What is your race/ethnicity? (Mark one.)

What is your gender? (Mark one.)

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* 18. What is your gender? (Mark one.)

What is your age?

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* 19. What is your age?

What is your marital status? (Mark one.)

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* 20. What is your marital status? (Mark one.)

What is your employment status? (Mark one.)

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* 21. What is your employment status? (Mark one.)

What is your annual family income range? (Mark one.)

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* 22. What is your annual family income range? (Mark one.)

Including yourself, how many people live within your household? (Mark one.)

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* 23. Including yourself, how many people live within your household? (Mark one.)

Please provide additional thoughts you would like to share:

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* 24. Please provide additional thoughts you would like to share:

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