Date:
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
Is the Caregivers Ministry Network your only employment?
Yes No
If no, how many hours per week do you work in addition to CMN hours?
Less than 10 10-20 20-30 30-40 over 40
Which services do you provide through Caregivers Ministry Network?
(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 experience, Check one answer per statement:
How satisfied are you with your overall experience as a service provider for Caregivers Ministry Network?
Strongly Agree Agree Disagree Strongly Disagree
How satisfied are you with the stipend amount you receive from CMN?
I feel respected by the families I work for through CMN.
I feel confident in providing services to the families I work with.
CMN offers enough training opportunities for me to improve my skills and abilities.
CMN staff is available when I have questions or concerns.
The hours I am able to work for CMN are sufficient to meet my needs.
Please include any additional comments you would like to make:
