NRCPT Intro Survey
Email
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Enter email address associated with your training account
(Q1) How did you HEAR ABOUT the Respite Care Training Program? Select all that apply.
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Internet search
Social media
State Agency
County agency
Conference
Family/Friend
Employer
Other (please describe in next question)
(Q2) If you selected "Other" in the last question, please describe it.
(Q3) What is the PRIMARY REASON you decided to take this training?
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My employer or county is requiring completion
My school or program of study requires completion
I am exploring a new job opportunity
I want to help care for a family member
I want to volunteer
For continuing education hours
So, I can be listed on the State Respite Registry
Other (please describe in next question)
(Q4) If you selected "Other" in the last question, please describe it.
(Q5) Have you received any PREVIOUS RESPITE TRAINING in the past?
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No
Yes (please describe in next question)
(Q6) If you selected "Yes" in the previous question, please describe.
(Q7) Do you currently work for an AGENCY that provides support to caregivers?
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Yes
No
(Q8) Are you a PRIMARY FAMILY CAREGIVER? Select all that apply.
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No
Yes, I am a primary caregiver of a child with special needs (0-18 years old)
Yes, I am a primary caregiver of an adult with special needs (18-65 years old)
Yes, I am a primary caregiver of an older adult (65+ years old)
(Q9) Have you provided respite care in the PAST?
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No
Yes
(Q10) Do you CURRENTLY provide respite care? Select all that apply.
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No
Yes, I am currently a respite provider for a child (0-18 years old)
Yes, I am currently a respite provider for an adult (18-65 years old)
Yes, I am currently a respite provider for an older adult (65+ years old)
(Q11) If applicable, how many YEARS OF EXPERIENCE do you have providing respite care?
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(Q12) If applicable, what is the average number of HOURS PER MONTH you currently provide respite care?
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(Q13) Which of the following GROUPS are you interested in providing respite care for? Select all that apply.
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Children (0-18 years old)
Adults (18-65 years old)
Older adults (65+ years old)
Individuals with physical disabilities
Individuals with dementia/ Alzheimer’s
Individuals with developmental disabilities
Individuals with behavioral disabilities
Individuals with mental health conditions
Individuals with chronic health conditions
Individuals with complex medical needs
Individuals receiving palliative or hospice care
Other
(Q14) Other (please describe in next question)
(Q15) How likely are you to provide respite care in the NEXT 6 MONTHS?
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Not likely at all
Less likely
Somewhat likely
Likely
Very likely
(Q16) What is your highest level of EDUCATION completed?
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Prefer not to answer
Some high school education
High School diploma or GED
Associate degree
Bachelor’s degree
Master’s degree
Doctoral degree
(Q17) What COUNTY do you live in?
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(Q18) Which of the following best describes the COMMUNITY in which you live?
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Rural (open country and towns or cities with fewer than 2,500 people)
Small town or city (towns or cities between 2,500 and 49,000 people)
Medium city (between 50,000 and 99,000 people)
Medium-large city (between 100,000 and 250,000 people)
Large city (over 250,000)
(Q19) What is your AGE in years?
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(Q20) Do you identify as TRANSGENDER?
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Yes
No
Prefer not to answer
(Q21) Which of the following best describes your GENDER IDENTITY?
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Prefer not to answer
Agender
Male
Female
Gender variant/non-conforming
Other (please describe)
(Q22) If you selected "Other" in the last question, please describe.
(Q23) Are you HISPANIC or LATINO?
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Prefer not to answer
Yes
No
(Q24) What is your RACIAL/ETHNIC background? Select all that apply.
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Prefer not to answer
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other (please describe)
(Q25) If you answered "Other" in the last question, please describe.
(Q26) What LANGUAGE do you use at home most often?
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Prefer not to answer
Spanish
Hmong
Arabic
Korean
Chinese
Vietnamese
Tagalong
English
Other (please describe in next question)
(Q27) If you answered "Other" in the last question, please describe.
(Q28) Do you identify as having a DISABILITY? Select all that apply.
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Prefer not to answer
No
Yes, cognitive
Yes, emotional
Yes, hearing
Yes, physical
Yes, visual
Other (please describe in next question)
(Q29) If you answered "Other" in the last question, please describe.
(Q30) What is your current TOTAL ANNUAL HOUSEHOLD INCOME (before taxes)?
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Less than $20,000
$20,000 to $44,999
$45,000 to $139,999
$140,000 to $149,999
$150,000 to $199,999
$200,000+
Prefer not to answer