Form 1 SCP Survey

Note: Dates to be updated based on date of OMB clearance for the information collection.

Your organization has been chosen to complete this survey. Reflecting a national random selection method, your organization represents similar programs we could not include in this year’s assessment. While participation in the survey is voluntary, your response is critical to providing a complete picture of our volunteer programs. The results of this survey will help convey to Congress the accomplishments of the SCP program and will more clearly establish its value to organizations like your own.

Please know that your responses to this data collection will be used only for purposes of this research.  The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific organization or individual.  We will not provide information that identifies individuals or their districts to anyone outside the study team, except as required by law.

COMPLETING THIS SURVEY FORM:

• This survey has been customized to address the types of activities carried out by SCP volunteers for your organization. This determination was based on communications with the Senior Corps Project Director who coordinates with your organization If you have not received the appropriate survey sections, please contact: Kathy Morehead, survey coordinator at Westat: 1-888-446-1292, or by e-mail, [email protected].

• The survey asks about SCP volunteer activities and accomplishments during the 12-month period from October 1, 2002 to September 30, 2003.

• Please review the Background Section and make corrections to the identifier information as needed.

• Please respond to the sections regarding your volunteers, your organization, and volunteer management.

• Please fill in the next section(s) with information about each of the activities that SCP volunteers carry out for your organization, specifically the numbers of SCP volunteers, SCP volunteer hours, and the nature of the accomplishments for a particular activity. Please avoid duplicating services—select the single best place, in your view, to describe an activity. Please refer to the sample item on page 8 as an example of how to complete the section(s). If numbers are hard to specify, please provide your best estimate.

• Describe any SCP volunteer activity for your organization that does not seem to fit any of the categories included here in the Other Services Section at the end of the survey form.

AFTER YOU HAVE COMPLETED THE SURVEY:

• After completing all parts of the survey, please make a copy for your records.

• Staple originals together and seal them in the envelope that is provided by Westat, the firm contracted to administer the survey.

• Return all sections of the survey to Westat by Friday, May 14. The full address is: Westat, Room RA 1225, 1650 Research Blvd., Rockville, MD 20850. If you wish to fax it: 1-888-377-5716.

If you have any questions about the survey, please contact Westat at (1-888-446-1292, [email protected]).

Public reporting burden for this collection of information is estimated to average 45 minutes per submission, including reviewing instructions, gathering and maintaining the data needed, and completing the form. Comments on the burden or content of this instrument may be sent to the Corporation for National and Community Service, Department of Research and Policy Development, 1201 New York Avenue, N.W., Washington DC 20525.

The Agency informs the potential person(s) who are to respond to this collection of information that such persons are not required to respond to the collection of information unless it displays a currently valid OMB control number, which is indicated on this form. (See 5 C.F.R. 1320.5(b)(2)(i))

Background

Your Organization:
Mailing Address:
City/State/ZIP
Person completing this form:
Your Name
Your Title
Your Telephone number:
Your Email:
Is your organization faith-based?				Yes		No

Your volunteerS

Senior Companions and Your Organization:

(all questions for the 12-month period October 1, 2002 through September 30, 2003)

Volunteer Information
a. Number of Senior Companions during that 12-month period (headcount)		SCP volunteers
b. Total Number of Senior Companion hours during the 12-month period		hours
c. Number of non-Senior Companion volunteers serving with your organization during the 12-month period (headcount)		non-SCP volunteers
d. Approximately how many of these non-Senior Companion volunteers were recruited, trained, managed, or coordinated by Senior Companion volunteers?
		non-SCP volunteers
e. Of the Senior Companions serving with your organization on October 1, 2002, approximately what percentage were still volunteering on September 30, 2003?
		%
f. How long has the Senior Companion program served with your organization? (Please select from the following responses): Under 1 year 1-5 years 6-10 years 11 years or more

Your Organization

Please check the most appropriate boxes for your organization.

HEALTH Hospital/Medical Center/Clinic Nursing Home/Convalescent Center/Hospice Home Health Care Agency Non-Residential Mental Health Agency Non-Residential Developmental Disability/ Rehabilitation Center Residential Long-Term Care Agency (MH/MR/DD) Congregate Meal/Meals on Wheels Agency Food Bank Government Agency Other Health Care Organization or Health Department; please specify HUMAN NEEDS Adult Day Care Center Transitional Shelter/Center (Homeless, Battered, etc.) Multi-Purpose Center (including senior centers) Public Housing Agency Government Agency Other Social Service/Human Needs Agency, please specify EDUCATION Library Museum Adult Education Organization Government Agency Other Educational Organization, please specify HOUSING Homeless Center Community-based Housing Organization Government Agency Other Housing Organization, please specify	COMMUNITY AND ECONOMIC DEVELOPMENT Community Development Program or Non-Profit Agency Thrift Shop/Coop/Craft Shop Chamber of Commerce Government Agency Other Community and Economic Development Agency, please specify PUBLIC SAFETY Court Adult Correctional Agency Police/Law Enforcement Agency Other Public Safety Organization, please specify
	DISASTER Red Cross Government Agency Other Disaster Organization, please specify
	HOMELAND SECURITY Red Cross Other Community-based Organization/ Agency Government Agency Other Homeland Security Agency, please specify OTHER Other Organization or Agency, please specify

VOLUNTEER MANAGEMENT

(For the 12-month period October 1, 2002 through September 30, 2003)

1. Please describe the extent to which Senior Companions provide the following benefits to your organization. (Check one choice for each statement)

	True to a great extent	True to a moderate extent	Not true	Not applic-able	Don’t Know
a. Senior Companions help expand the types of service to clients.					
b. Senior Companions help increase the number of clients served.					
c. Senior Companions help improve the quality of services provided.					
d. Senior Companions help free up paid staff time.					
e. Senior Companions bring specialized skills, such as legal, financial management, or computer expertise.					
f. Senior Companions help increase public support for our organization and/or improve community relations.					
g. Senior Companions help recruit other volunteers (non-Senior Companion).					
h. Senior Companions help manage other Senior Companions.					
i. The Senior Companion project reduces the time and effort needed to recruit volunteers who can help meet our agency’s needs.					
j. Other reason (Specify):					

2. Please describe the extent to which your organization uses tools to manage Senior Companion Volunteers. (Check one choice for each statement)

Management of Senior Companion volunteers	Used to a great extent	Used to a moderate extent	Not used	Not applic-able	Don’t Know
a. Written policies and volunteer assignment descriptions for Senior Companion volunteers.					
b. Liability coverage or insurance protection for Senior Companion volunteers.					
c. Recognition activities, such as award ceremonies, for Senior Companion volunteers.					
d. Regular collection of information on numbers and hours of Senior Companion volunteers.					
e. Annual measurement of the impacts of Senior Companion volunteers.					
f. Training and professional development activities for volunteers.					
g. Screening procedures to identify suitable Senior Companion volunteers, and to match them with appropriate tasks or jobs.					
h. Regular supervision of and communication with Senior Companion volunteers.					

3. We are interested in knowing if anyone in your organization is primarily responsible for volunteer management. (Please check “yes” or “no”)

Staff responsibility for volunteer management	Yes	No	Don’t know
a. Does your organization have a paid staff person whose responsibilities include management of volunteers?		 (Go to Item 4)	
b. Does your organization have a volunteer who is responsible for the management of other volunteers?			

4. Some organizations encounter challenges with Senior Companions or the Senior Companion project. Please note the degree to which each of the following issues has been a challenge for your organization. (Please check one choice for each statement below)

Challenges in the development of Senior Companion volunteer assignments	A major challenge	A minor challenge	Not a challenge at all	Not applic-able	Don’t Know
a. Responsiveness of the Senior Companion project when:
More Senior Companion volunteers are requested.					
Senior Companion volunteers with the right skills or expertise are needed.					
Senior Companion volunteers are needed for specific schedules.					
b. Lack of paid staff time to properly train and supervise Senior Companion volunteers.					
c Lack of adequate funds for supporting Senior Companion volunteer involvement.					
d. Regulatory, legal, or liability constraints on Senior Companion volunteer involvement.*					
e. Absenteeism, unreliability, or low quality service provided by Senior Companion volunteers.					
f. Other challenge (Specify):					

* constraints might include reporting, background checks, or liability insurance

5. To what extent would each of the following factors increase your capacity to involve volunteers in service (both Senior Companion and non-Senior Companion)?

	Would increase to a great extent	Would increase to a moderate extent	Would not increase at all	Don’t Know
a. More training or professional development in how to work more effectively with volunteers.				
b. Greater availability of potential volunteers with specialized skills, such as legal, financial management, or computer expertise.				
c. A one-year, full-time volunteer with a living stipend, and with responsibility for volunteer recruitment and management.				
d. Fewer regulatory, legal, or liability constraints on volunteer involvement.				
e. More information about people in the community who want to volunteer.				
f. Other factor (Specify):				

6. We’d like to know about the methods your organization uses to locate and recruit Senior Companion volunteers. Does your organization…

	Yes	No	Not applic-able	Don’t Know
a. Do public speaking before groups?				
b. Use radio?				
c. Use the Senior Corps JASON web-based recruitment system?				
d. Use other (non-JASON) Internet recruiting system(s)?				
e. Use television?				
f. Use newspapers, trade papers, billboards, or fliers?				
g. Register with other organizations to receive referrals?				
h. Use special events, such as volunteer fairs or organizational open houses?				
i. Use word of mouth?				
j. Other method (Specify):

Sample SCP Volunteer Activity

Below is an example of how to complete the items regarding accomplishments.

Sample. Delivery of Health Services

N umber of Senior Companions who provided these services:	30
Total number of Senior Companion Volunteer hours:	3,000

Type of Service	Number
Provided escort and support services in community clinics, home health agencies, and other health settings to	150	frail adults in community clinics.
Provided services at a clinic, hospital, mobile-unit, skilled nursing facility, or adult day care center to	500	frail adults.

HUMAN NEEDS: HEALTH/NUTRITION (HN)

HN-a. Total estimated number of people who benefited:

Please answer the following questions for the 12-month period October 1, 2002 through September 30, 2003. Respond for only those categories that best describe a Companion activity.

HN-1. Delivery of Health Services

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Provided escort and support services to		frail adults in community clinics.
Provided services at a clinic, hospital, mobile-unit, skilled nursing facility, or adult day care center to		frail adults.
Provided information on the delivery of health services to		frail adults.
Helped		frail adults to prepare for/recover from operations.
Visited with/nurtured		hospitalized frail adults.

HN-2. Mental Health

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Provided support services to		frail adults with mental health impairments.

HN-3. Developmental Disabilities

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Provided support services to		frail adults with developmental disabilities.

HN-4. Substance Abuse

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Distributed informational fliers on the abuse of alcohol, prescription and illegal drugs, and over-the-counter medications to		people.
Provided services to		frail adults and their families who participated in substance treatment, rehabilitation, or support groups.

HN-5. Physical Disabilities

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Provided information on coping with physical disabilities to		frail adults.
Provided rehabilitation, exercise, and other services to		frail adults with physical disabilities.

HN-6. In-Home Care

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Assisted with grooming, dressing and other daily tasks For		frail adults in their homes.
Provided information on health, nutrition, and other in-home services to		frail adults.
Provided services such as light housekeeping, meal preparation, and nutritional education to		frail adults in their homes.
Enabled the organization to expand in-home care services to an additional		frail adults.
Enabled the organization to offer new in-home services for		frail adults.
Informed case management professionals about potential problems or needed services for		frail adults.
Provided peer counseling, wrote letters, visited, listened, read, and spoke with		frail adults to ease their feelings of loneliness.

HN-7. Hospice/Terminally Ill

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Provided information about hospices and other services for the terminally ill to		frail adults and their families.
Nurtured and supported		terminally ill adults and their families.

HN-8. HIV/AIDS

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Provided information on HIV/AIDS programs to		frail adults.
Nurtured and supported		frail adults with HIV/AIDS living in hospices, hospitals and in their homes, and their families.

HN-9. Other Health/Nutrition Services

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Please specify these other health/nutrition services:
(1) , to…		people.
(2) , to…		people.
(3) , to…		people.

OTHER HUMAN NEEDS (O)

O-a. Total estimated number of people who benefited:

Please answer the following questions for the 12-month period October 1, 2002 through September 30, 2003. Respond for only those categories that best describe a Companion activity.

O-1. Adult Day Care

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Provided supportive services and social activities at adult day care centers for		adults.

O-2. Companionship/Outreach

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Counseled, provided support, wrote letters, listened, read or spoke to		people to ease their feelings of isolation and loneliness.
Visited, called or provided bereavement support to		people.
Visited with		hospitalized patients.

O-4. Respite

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Provided information on respite programs to		frail adults and their caregivers.
Provided respite for		caregivers of frail adults.

O-5. Senior Citizens Assistance

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Please describe any specific Senior Citizens Assistance services:
(1) , to…		people.
(2) , to…		people.
(3), to…		people.

O-6. Senior Center Programs

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Provided supportive services and social activities at senior centers to		frail adults.

O-7. Elder Abuse/Neglect

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Assisted		frail, abused elders and their families.

O-8. Other Human Needs Services

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Please specify these other human needs services:
Type of Service	Number
(1) , to…		people.
(2) , to…		people.
(3) , to…		people.

COMMUNITY AND ECONOMIC DEVELOPMENT (CED)

CED-a. Total estimated number of people who benefited:

Please answer the following questions for the 12-month period October 1, 2002 through September 30, 2003. Respond for only those categories that best describe a Companion activity.

CED-1. Transportation Services

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Drove		people for grocery shopping, errands and doctor visits.
Drove people for grocery shopping, errands and doctor visits for		miles.

CED-2. Senior Companion Leaders

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Recruited new Senior Companions to serve with your organization, totaling……………………………………………	_________	new Senior Companion
Coordinated and helped to manage volunteer teams involving		volunteers.

CED-3. Other Community and Economic Development Services

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Please specify these other Community and Economic Development services:
(1) , to…		people.
(2) , to…		people.
(3) , to…		people.

PUBLIC SAFETY (pS)

PS-a. Total estimated number of people who benefited:

Please answer the following questions for the 12-month period October 1, 2002 through September 30, 2003. Respond for only those categories that best describe a Companion activity.

PS-1. Safety/Fire Prevention/Accident Prevention

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Identified and reported		safety problems (e.g., home safety, fire prevention, auto safety, traffic/pedestrian control problems).
Identified and reported safety problems affecting		frail adults.

PS-2. Crime Awareness/Crime Avoidance

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Identified and reported		potential crime problems.
Identified and reported potential crime problems affecting		frail adults.
Provided safety escort services to		frail adults.
Provided information on ways to avoid victimization, such as direct deposit services and scam alerts, to		frail adults.

PS-3. Other Public Safety

Number of Senior Companions who provided these services:
Total number of Senior Companion Volunteer hours:

Type of Service	Number
Please specify these other public safety services:
(1) , to…		people.
(2) , to…		people.
(3) , to…		people.

HOUSING (h)

H-a. Total estimated number of people who benefited:

Please complete those items that are relevant to your SCP volunteers for the period October 1, 2002 through September 30, 2003.

H-1. Homeless

Number of SCP Volunteers who provided these services:
Total number of SCP Volunteer hours:

Type of Service	Number
Participated in programs to help the homeless (except for housing referrals) attended by		people.

H-2. Other Housing Services

Number of SCP Volunteers who provided these services:
Total number of SCP Volunteer hours:

Type of Service	Number
Please specify these other housing services:
(1) , to…		people.
(2) , to…		people.
(3) , to…		people.

EDUCATION (ED)

ED-a. Total estimated number of people who benefited:

Please complete those items that are relevant to your SCP volunteers for the period October 1, 2002 through September 30, 2003. Items related to education for children have been excluded.

ED-1. ESL

Number of SCP Volunteers who provided these services:
Total number of SCP Volunteer hours:

Type of Service	Number
Provided information, program enrollment, or referrals on ESL programs to		people.
Helped		adult ESL students to learn English.

ED-2. Service Learning

Number of SCP Volunteers who provided these services:
Total number of SCP Volunteer hours:

Type of Service	Number
Reflected on their volunteer experiences and described their insights concerning service, client advocacy, social issues and their own lives by		volunteers.

ED-3. Adult Education and Literacy

Number of SCP Volunteers who provided these services:
Total number of SCP Volunteer hours:

Type of Service	Number
Provided literacy assistance to		adults.

ED-4. Other Education Services

Number of SCP Volunteers who provided these services:
Total number of SCP Volunteer hours:

Type of Service	Number
Please specify these other education services:
(1) , to…		people.
(2) , to…		people.
(3) , to…		people.

DISASTER (D)

D-a. Total estimated number of people who benefited:

Please complete those items that are relevant to your SCP volunteers for the period October 1, 2002 through September 30, 2003.

D-1. Disaster Preparedness

Number of SCP Volunteers who provided these services:
Total number of SCP Volunteer hours:

Type of Service	Number
Provided information, class enrollment, or referrals on natural disaster preparedness to		people.
Were on “on-call” lists for		emergencies or needs.
Prepared disaster plans for		homebound seniors.
Helped seniors prepare for, cope with and understand what to do in the event of emergencies / disasters		seniors.

D-2. Other Disaster Services

Number of SCP Volunteers who provided these services:
Total number of SCP Volunteer hours:

Type of Service	Number
Please specify these other disaster services:
(1) , to…		people.
(2) , to…		people.
(3) , to…		people.

OTHER SERVICES (OS)

Activity not included in survey	Specific activity performed by Senior Companion	Number of Senior Companion Volunteers Performing Activity	Total Number of Hours Spent on Activity	Number of People Served by the Activity
Language Assistance	Language interpretation	8	200	16

Please add any additional information on the reverse side of this page.

2 SCP

Draft: March 25, 2004