Form 2 Caregiver Survey

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 …

	Strongly Disagree	Somewhat Disagree	Somewhat Agree	Strongly Agree
… I feel less lonely.	1	2	3	4
… I feel I have close ties to more people.	1	2	3	4
… I am able to do more of the things I need to do.	1	2	3	4
… I am able to do more of the things I want to do.	1	2	3	4
… I am able to get short-term rest and relief.	1	2	3	4
… I am able to find time to run errands.	1	2	3	4
… I am able find time to attend to my personal and health care needs.	1	2	3	4
… I am more satisfied with my life.	1	2	3	4
… The person I care for is able to remain at home.	1	2	3	4
Overall, I am satisfied with the Caregiver Respite Senior Companion volunteer.	1	2	3	4
Overall, the Senior Companion Program has met my expectations.	1	2	3	4

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OMB Control Number: 3045-0146 Expires: 10/31/2015