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1. If a respite service with qualified parents of other special needs children and/or professionals provided this care, how likely would you be to utilize the service?

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I would use this service
I would be likely to use this service
I would be unlikely to use this service
I would not use this service

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2. If you could choose a day and time for this service to be offered which would you prefer?

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Week days, after school
Weekends, day hours
Weekends, evening hours
Week nights, evenings

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3. How much would you be willing to pay for this service?

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4. Would you be willing to pay for this service in part by volunteering your time, in kind, to care for other special needs children on a different night?

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I would do this

I would be likely to do this

I would be unlikely to do this

I would not do this

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5. What would make this a valuable service to you?

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6. What activities would you like to see your child engaged in while they are utilizing respite care?

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Social skills activities

Independent living skills

Sport activities

Art activities

Academic skills enhancement

Community inclusion activities

Safety skill activities

Sensory Integration

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7. Would you be more likely to use this service if your child's respite time was spent with his typically developing peers?

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I would be more likely
I would be less likely
I have no preference
I would prefer my child be with other disabled children only

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8. If scholarships were made available based on income to pay for this service would this enhance the service for you?

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Yes
Maybe
No
Not likely

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9. What is the biggest challenge you face in obtaining respite care?

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Finding a skilled person to provide the care

Finding a trust worthy person who will provide the care

Finding a willing person to provide the care

Paying someone to provide the care

Leaving your child with anyone other than family

Fear for your child

other

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10. Please tell us your personal concerns with a system of respite care to assist parents with intellectually disabled children.

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11. Please indicate your highest level of education.

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Less than high school
High school
Trades
College
University Degree
Post-Graduate Degree
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12. Please indicate your age group.

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16-18
19-24
25-34
35-44
45-54
55-64
65-69
70-79
80 +
Decline to answer

13. Please indicate your household income level.

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Under $10,000
$11,000 to $15,000
$16,000 to $20,000
$21,000 to $25,000
$26,$00 to $30,000
$31,000 to $35,000
$36,000 to $40,000
$41,000 to $45,000
$45,000 to $50,000
above $50,000

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14. Please tell us how we may contact you in the future with updates regarding our desire to provide a quality respite service for children with intellectual disabilities.

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