Lifespan Respite
Technical Assistance Center

State Lifespan Respite Performance Measurement and Data Tools

For more on Performance Measurement,
 visit here.

For more sample measurement toolsvisit here.

Data Elements

South Carolina

Data Elements for Lifespan Respite Reporting



HEARTS Pre and Retrospective Post Test Form 


2018 Lifespan Respite Care Survey - for family caregivers post receipt of respite Grants/Vouchers


         Financial Assistance Evaluation Form 

Respite Care I&R Evaluation Form  

DE RespiteOnline Referral Service Evaluation Form 

DE Financial Assistance Survey Results 


Montana Post Respite Voucher Satisfaction Survey with caregiver outcomes


Family Caregiver Depression Screening

Nebraska Lifespan Respite Network: Producing Positive Outcomes for Families 2015-2017 Evaluation Final Report, UNMC-MMI and DHHS. The evaluation demonstrated respite services resulted in a range of family caregiver outcomes, including fewer health symptoms reported by family caregivers and less relationship strain with the care recipient. Read the Executive Summary

2017 NE Lifespan Respite Family Caregiver Survey for caregivers receiving NE Lifespan Respite Subsidy families, with supplemental questions.

The supplemental questions are used by the local Respite Network Coordinators for all initial and renewal clients at the time of eligibility determination notification. Calling the family caregiver is done by the Respite Coordinator when receiving notice from the Lifespan Respite Subsidy Social Services Worker (SSW) that eligibility has been completed. This interaction provides an opportunity to begin building (or enhance an existing) relationship with the family caregiver. Goal is to enable families to have confidence in contacting the local respite network if there are concerns or questions.

Nebraska Lifespan Respite Subsidy 2015 Evaluation Report, September 2015


Final Report 2021 - Caregiver Respite Self-Directed Pilot

NV Pre and Post Respite Caregiver Surveys (Rx - 2019)

NV Pre and Post Respite Caregiver Surveys (Expansion Grant 2011)

LifeCourse Tool

Nevada Lifespan Respite Care Program Data on Caregivers 2012, Final Report 

Nevada Helping Hands of Vegas Valley 

Respite Care Voucher Program Application (includes Pre-Survey)

Caregiver Respite Satisfaction Survey

Caregiver Results

HHOVV Caregiver Retrospective Survey Caregiver Letter

NV Respite Pre Respite Survey

NV Respite Rx POST Respite Survey

Post Survey Results

Pre Survey Results

New Hampshire

NH LRC Coalition Logic Model 

New York

NY Post-Respite Survey

New York’s Lifespan Respite Evaluation Plan for the 2014-2017 grant award

Lifespan Respite Care Program: Advancing State Lifespan Respite Systems - New York, Program Evaluation Report

North Carolina

NC Pre  and Post  Caregiver Respite Surveys

Mini-Grant Tools and Reports

Setting Goals to Maximize Your Respite Time Tool
Mini-grant Summary Tables
Mini-grant Summary Report, March 2012-May 2013
Caregiver Survey  Results  


OK Voucher Program - Respite Pre and Post Respite Caregiver Outcome Surveys


CareBreak Retrospective Survey

CareBreak PreService Survey

CareBreak PostService Survey


Caregiver Survey 


Satisfaction Survey 2022

Respite Voucher Reimbursement Packet 2022 (includes surveys)

Organizational Success and Capacity


Tools for evaluating MA state level strategic alliance:

Levels of Organizational Integration Rubric

LOIR Template

Utilizing Collaboration Theory

Evaluating Organizational Collaborations



DE Choice of Respite Care Provider by 2010 Financial Assistance Recipients 

DE Demographics of Respite Recipients 

PPT of Yearly Summary of DE Demographic Descriptors 


NE Annual Report of Activities, Outcomes and Individuals Served 

North Carolina

NC Lifespan Respite Mini-Grantee Quarterly Reporting Form 



Lifespan Respite

Technical Assistance and Resource Center

ARCH National Respite Network and Resource Center

(703) 256-2084 |

This project is supported, in part by grant number 90LT0001, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.


The ARCH National Respite Network and Resource Center is a program of Families and Communities Rising |4220 NC Hwy 55, Suite 330, Durham, NC 27713 |



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