Please provide the following information about yourself, as an individual providing respite:

1) How many hours would you provide per week?

Less than 10 hours 21-25 hours 11-15 hours 26-30 hours 16-20 hours 31-40 hours

2) What populations do you serve? (check all that apply)

Alzheimer’s Mental Illness Behavioral Disorders Physical Disabilities

Chronic Illness Risk of Abuse and/or Neglect Developmental Disabilities

Frail Elderly Medical Needs Other (please specify)

3) What age group(s) do you serve? (check all that apply)

0-2 years 6-18 years 19-64 years 3-5 years 65 & over All ages

4) Check the payment sources you are willing to receive.

Medicaid Waiver Private Pay Respite Subsidy Foster Care

Social Services Block Grant Early Intervention SSI/Disabled Children’s Program

Disabled Persons & Family Support Medically Handicapped Children’s Program

Other (please specify)

5) On average, how much do you charge for respite services?

$ Average Hourly Fee Volunteer/Accept no fee Accept Donations Sliding Scale

Other (please specify)

6) Are you willing to provide respite services during special hours? If so, when? (check all that apply)

Days Evenings Overnight Weekends Emergencies

Extended periods (please specify)

7) Where do you provide respite? (check all that apply)

In the client’s home In my home Adult Day Care Facility Child Care Facility Hospital Nursing Home Facility

Other (please specify)

8) While providing respite or in addition to providing respite,
is there any other assistance you provide or are willing to provide? (check all that apply)

Assistance with bathing Occupational Therapy Chores (errands) Respiratory Therapy

Light housekeeping duties Other (please specify)

Physical Therapy Speech Therapy

9) What is your primary language?

10) What geographic area(s) do you serve? (list towns, cities, or counties):

11) List any specialized training you’ve had. (please explain)

12) Is this your first time providing respite? Yes No

13) If not, how many years have you been providing respite?

0-1 years 2-3 years 4-6 years 7-10 years 11 years or more

14) Are you willing to travel outside of your community to provide respite services?

Yes No

15) If so, what distance are you willing to travel?

Less than 10 miles 26-50 miles 11-25 miles 51 miles or more

16) Is your home accessible (barrier-free)? Yes No

17) Would you be willing to provide references? Yes No

18) Would you be willing to offer transportation to a client? Yes No

19) Are you covered by auto insurance? Yes No

20) Do you have a valid Nebraska driver’s license? Yes No

21) Do you want your name to be available for referrals through the Nebraska Health and Human Services
Statewide Respite Provider Database to provide respite services to families? Yes No

22) Do you know any other person(s) who provide respite services or might be interested in providing
respite services? If so, please list their names and phone numbers.

23) How did you hear about us?

Survey Newspaper Radio Brochure Presentation Friend/Family

Other (please specify)

24) Comments or Suggestions: