Design for Survey of Persons with Mental Retardation and Developmental Disabilities: Summary of Recommendations for Survey Questions and Screening Criteria. Design for Survey of Persons with Mental Retardation and Developmental Disabilities: Summary of Recommendations for Survey Questions and Screening Criteria : Table 23

11/29/1989

: Table 23

Number of Informal ProvidersList all names (specify primary provider)
Relationship/ Description of Provider to IndividualRelationship to individual: parent, brother/sister (in-laws), spouse, child, other relative, non-relative Gender: male/female Lives with sample member: yes/no
Non-Monetary Types of Service/AssistancePersonal care, housekeeping/house maintenance, meals, medication/medical treatment, managing finances or legal matters, grocery/other shopping, transportation, supervision
Amount of Assistance ProvidedWhen: weekday days, evenings, during the nights, weekend days Hours per week (Monday-Friday), __________ (write-in) Hours per weekend, __________ (write-in)
Monetary Types of Services/Assistance Including Purchasing Clothes/Groceries, etc.Groceries, clothing, housing (rent, mortgage, utilities, payments for personal care/housekeeping/other assistance, medicine/supplies, treatment, cash, other
Amount of ExpensesAverage for week or month $__________ (write-in)