SENIOR COMPANION PROGRAM
RESPITE PERFORMANCE MEASURE SURVEY
Thank you for taking the time to complete this survey. We would like to know how the Senior Companion Volunteer who has been providing respite care to you has affected your life (as the caregiver).
All information will be kept confidential; please do not disclose your name. You may choose not to answer questions.
This 1st question is about how many hours of respite service you receive in a typical week from your senior companion.
Tell us how many TOTAL HOURS in a typical week you received respite services.
Here is an example of how Mrs. Smith (the caregiver) would answer question #1:
Her Senior Companion usually provides respite care by spending time with the person in Mrs. Smith’s care. The Senior Companion comes to the home for one hour on Monday and two hours on Wednesday. Therefore, the total hours a week that Mrs. Smith receives respite services is 3 hours a week.
1. In a typical week, how many hours does your Senior Companion Volunteer provide respite services? |
hours of respite |
Please turn the page for questions 2-12
Because I Have a Senior Companion Volunteer assisting with Respite Care …
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page
OMB Control Number: 3045-0146 Expires: 10/31/2015
File Type | application/msword |
File Title | SENIOR COMPANION PROGRAM |
Author | cdm |
Last Modified By | Borgstrom, Amy |
File Modified | 2013-01-23 |
File Created | 2013-01-23 |