4 Respite Survey

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RESPITE PERFORMANCE MEASURE SURVEY

OMB Control Number: [3045-XXXX]

Expiration Date: 10/31/2024

Thank you for taking the time to complete this survey. We would like to know how the AmeriCorps Seniors volunteer who has been providing respite care 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 a question.

This 1st question is about how many hours of respite service that you may have received in the past 4 weeks from your AmeriCorps Seniors volunteer.

Tell us how many TOTAL HOURS in a typical week you received respite services.

Here is an example of how Mrs. Jones would answer question #1:

Her AmeriCorps Seniors volunteer usually spends one hour on Monday with and two hours on Wednesday providing respite services. Therefore, the total hours a week that she receives respite services is 3 hours a week.

1. In a typical week, my AmeriCorps Seniors Volunteer is with me for

hours of respite

Please turn the page for the questions 2-12

Because I have a AmeriCorps Seniors volunteer assisting with Respite Care …

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

250 E Street SW

Washington, D.C. 20525

202-606-5000/ 800-942-2677