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CSCL's ShareVision Home Page > Surveys  > New Survey

New Survey: Caregiver Written Interview

HEADER - Required Fields
Header Section - #FE9A2E
Year *
Date *
Select a date from the calendar.
Applicant Name *
Header - Why do you want to be a caregiver?
Header Section - #95B3D7
Why Caregiving? *
How did you hear about this service, why this field, and what made you interested in providing care?
What does the term "people with developmental disabilities" mean to you? *
Tell us about yourself *
What would you like us to know about you or your family that would make us want to consider you as a potential caregiver?
How are you involved in your community? *
i.e., church activities, sporting activities, and other family events
How would you provide an environment consistent with the family's expectations? *
i.e., bedtime routines, eating schedules, discipline, etc.
How would you introduce and include a person to a new community? *
What kind of positive differences could you add to an individual's life? *
Header - Support Needs
Header Section - #95B3D7
Alternative Communication *
Some of the individuals we serve have difficulty communicating verbally. Describe other forms of communication that you are experienced with.
Individual Support Needs
Which of the following support needs or behaviours would you NOT be comfortable providing support to? Check all that apply.
Comment on why you have selected from the list above *
Header - Positive Behavioural Supports
Header Section - #95B3D7
PBS - 1 *
What behaviours do you/would you find it necessary to intervene for?
PBS - 2 *
What does the phrase positive behavioural support mean to you?
PBS - 3 *
What steps would you take to minimize the reoccurrence of challenging behaviours?
PBS - 4 *
How would you explain an individual's negative behaviour to their parent/caregiver/support network?
PBS - 5 *
Give an example of how you would express approval.
Header - Individual Rights & Standards
Header Section - #95B3D7
Safety *
When you work with people with developmental disabilities, what would you consider to be good safety guidelines?
Privacy *
Describe some situations in which you believe an individual would require privacy?
Confidentiality *
Describe a situation in which you would need to protect and respect and individual's right to confidentiality.
Header - Household Readiness
Header Section - #95B3D7
Limitations and Expectations *
What are your limitations in regards to care giving, and what expectations of the Society do you have in regard to supporting you to provide care?
Training *
Are you open to further training? If so, what further education or training do you feel would be beneficial in providing care? (courses you would like to participate in)
Children or Others in the Home - 1 *
Have you discussed providing care with your children or others residing in the home?
Children or Others in the Home - 2 *
Please comment on their reaction to the idea of home sharing or respite:
Children or Others in the Home - 3 *
Could they tolerate sharing their parents(s) and their belongings with another person? Please provide examples.
Children or Others in the Home - 4 *
How would you approach the potential transference of behaviours between an individual and your children? Please provide examples of what you think these behaviours might include:
Household Expecations and Limits *
What are the household expectations and limits in your home? (Rules, responsibilities, etc.)
Home Safety Requirements *
What, if any, safety precautions would you undertake to make your home safe for an individual?
Supporting Relationships *
How open and sensitive will you be to the parent and/or sibling and/or Representative "popping" in or calling during their child/family member's stay with you?
Manager Visits *
How do you feel about the CSCL HomeShare/Respite managers visiting you and phoning you while the individual is in care?
Do you have any questions or comments for us?
By checking this box, I declare that the information contained in this interview is true to the best of my knowledge and that I have not omitted information requested. Please click "OK" to submit your record.
View *
This field contains information used by the system. Please do not modify or delete.