Adult Day Center 1. Default Section Question Title * 1. How would you, a family member, or friend utilize an Adult Day Center? Respite (This provides a scheduled break or relief for the caregiver) Full-Time (8 plus hours per day, scheduled) Part-Time (Less than 8 hours per day, scheduled) Drop-in (Sporadically, emergency situations, unscheduled) Question Title * 2. What hours of operation would best fit your schedule? 7 am - 6 pm 6 am - 5 pm 7:30 am - 5:30 pm Other (please specify) Question Title * 3. Which days of the week would the participant attend? (Check all that apply.) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Question Title * 4. Which nonmedical services would the participant need? (Check all that apply.) Medication Reminders Breakfast Lunch Dinner Toileting Bathing Laundry Transportation to appointments Transportation from home to center Transportation from center to home Other (please specify) Question Title * 5. Which resources would the participant have available to cover costs? (Check as many as needed.) Long Term Care Insurance Private/Personal Resources Health Insurance Medicaid Question Title * 6. Adult care centers across North Dakota charge approximately $50 per day. Would this rate be feasible for your situation? Yes No Question Title * 7. If you, a family member, or friend are in need of care, please rate how likely you would be to use a day center. Yes, I would use it! Please sign me up now. I would use this. I think I would use this. I probably wouldn't use this. No, I wouldn't use this. Other (please specify) Question Title * 8. If you would like to be contacted with further information regarding this potential program, please provide your name and phone number. (Optional) Done