Last Name: First Name:
Please answer the following questions about yourself:
Age: under 20 20-30 31-40 41-50
51-60 61-70 71-80 81-90 90+
Gender: Male Female
Race/Ethnicity: Black/African American White/Caucasian
Native American Asian/pacific Islander
Hispanic/Latino Other
Are you currently employed outside of the home?
Yes No
If yes, how many hours per week do you work?
Less than 10 10-20 20-30 30-40 over 40
How satisfied are you with the over all services of Caregivers Ministry Network?
Very Satisfied Somewhat Satisfied Not Satisfied
Which services does Caregivers Ministry Network assist you with?
(Please check all that apply)
Information and Referral Transportation
Personal care Chores
Errands Respite
Other1: Other2:
Please answer the following questions concerning your Caregivers Ministry Network service provider:
My CMN service provider is on time.
Strongly Agree Agree Disagree Strongly Disagree
My CMN service provider has a positive attitude.
The services my CMN service provider supplies are helpful to me.
My CMN service provider completes tasks well.
My CMN service provider is willing to do extra tasks when needed.
My CMN service provider’s hours are sufficient to meet my needs.
Please answer the following questions about your loved one:
Age: under 20 20-30 31-40 41-50 51-60
61-70 71-80 81-90 90+
What is your loved one’s current medical condition?
High Blood Pressure Diabetic Alzheimer’s Cancer
Depression Stroke Heart Other:
What is your loved one’s current functional status?
Ambulatory shortness of breath
Incontinence: Bowel Bladder
Impairment: Speech Vision Hearing
Other
Please include any additional comments you would like to make:
