46. Who is the primary caregiver being relieved?____________________________________________________________
47. Is the frequency of respite care adequate?______________________________________________________________
48. In what ways could respite care be improved? ___________________________________________________________
□
Complete if Attendant Care Services are on the PCSP:
N/A
49. How many attendants come to your home to help you?____________________________________________________
□
□
50. Did you hire the attendants that come to your home?
Yes
No
If no, what agency sent the aides or companions that come to your home? ___________________________________
________________________________________________________________________________________________
□
□
51. Are you related to your attendants?
Yes
No
If yes, how are you related to them?
__________________________________________________
________________________________________________________________________________________________
52. How long have your attendants worked with you? ________________________________________________________
53. Does your paid caregiver live in the home with you? If yes, provide his/her name?_______________________________
□
□
54. Have you had a change in the attendants working for you in the last 6 months?
Yes
No
If yes, how many times and why?
________________________________________________________________________________________________
________________________________________________________________________________________________
55. How long do your attendants usually stay each visit?______________________________________________________
□
□
56. Is the amount of time good for you?
Yes
No
□
□
If no, is it
Too long
Not enough time
57. How do your attendants help you? (List tasks and be specific) _______________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
58. What are your attendants not doing that you would like them to do?
Please list and be specific.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
□
□
59. Do your attendants come the same time every day?
Yes
No
□
□
60. Does someone help you take a bath?
Yes
No
If yes, who__________________________________________
5
DMS-690 (1-1-16)