Caregiver Respite Grant Program
Customer Satisfaction Survey Template

Question Title

* 1. First and Last Name:

Question Title

* 2. Overall, how satisfied or dissatisfied are you with the application process of RCAW's Caregiver Respite Grant Program?

Very satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Very dissatisfied

Question Title

* 3. Did you find the processes involved in applying for assistance via the Caregiver Respite Grant program user friendly?

Extremely friendly

Very friendly

Somewhat friendly

Not so friendly

Not at all friendly

Question Title

* 4. Were you happy with the respite you received as a result of RCAW's Caregiver Respite Grant Program?

A great deal

A lot

A moderate amount

A little

Not at all

Question Title

* 5. What did you do with your 'respite' time?

Spent time with spouse/significant other

Spent time with other family members

Participated in social/recreational activities? i.e. church, visit with friends, go to a concert, etc.

Run errands

Completed household tasks

Had private time to relax, rest, read, pursue hobbies/interests?

Participate in physical activities or exercise

Go to medical appointments

Tended to own health care needs

Other (please specify)

Question Title

* 6. How likely are you going to apply to the Caregiver Respite Grant Program again?

Very likely

Likely

Neither likely nor unlikely

Unlikely

Very unlikely

Question Title

* 7. What are the top three (3) challenges that you have as a family caregiver? Select up to three answers.

Financial (respite costs)

Feeling overwhelmed

Physical, medical, or other personal health challenges

Lack of sleep

Depression/anxiety

Social isolation

Strain on relationship with other family members

No challenges - all is good!

Other (please specify)

Question Title

* 8. Did the Caregiver Respite Grant Program help or relieve any of the challenges you identified above?

Yes

If no, what could we do better to help you address any challenges you identified?

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* 9. Do you have any other comments, questions, or concerns?

Question Title

* 10. Any suggestions on what we can do to improve our Caregiver Respite Grant Program?

Yes, please see below.

No, not at this time.

If yes, please specify

Caregiver Respite Grant ProgramCustomer Satisfaction Survey Template

Question Title

* 1. First and Last Name:

Question Title

* 2. Overall, how satisfied or dissatisfied are you with the application process of RCAW's Caregiver Respite Grant Program?

Question Title

* 3. Did you find the processes involved in applying for assistance via the Caregiver Respite Grant program user friendly?

Question Title

* 4. Were you happy with the respite you received as a result of RCAW's Caregiver Respite Grant Program?

Question Title

* 5. What did you do with your 'respite' time?

Question Title

* 6. How likely are you going to apply to the Caregiver Respite Grant Program again?

Question Title

* 7. What are the top three (3) challenges that you have as a family caregiver? Select up to three answers.

Question Title

* 8. Did the Caregiver Respite Grant Program help or relieve any of the challenges you identified above?

Question Title

* 9. Do you have any other comments, questions, or concerns?

Question Title

* 10. Any suggestions on what we can do to improve our Caregiver Respite Grant Program?

Caregiver Respite Grant Program
Customer Satisfaction Survey Template