{"id":1397185,"date":"2025-12-19T14:51:21","date_gmt":"2025-12-19T19:51:21","guid":{"rendered":"https:\/\/fcsn.org\/?p=1397185"},"modified":"2025-12-19T14:51:21","modified_gmt":"2025-12-19T19:51:21","slug":"c2cmatchsurvey-6weeks","status":"publish","type":"post","link":"https:\/\/fcsn.org\/vi\/c2cmatchsurvey-6weeks\/","title":{"rendered":"C2C Respite Form Post-Match Survey (6 Weeks)"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of 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      <\/div><form method='post' enctype='multipart\/form-data'  id='gform_73'  action='\/vi\/wp-json\/wp\/v2\/posts\/1397185' data-formid='73' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LdJN-osAAAAAGaA3QLEIzmlcFHE8ixEcZ6Q6M7Y' data-tabindex='0'><input id=\"input_3b3f45f7aab0dfae80850c5d9768580c\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_3b3f45f7aab0dfae80850c5d9768580c\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_73' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_73_50\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_73_50'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_73_50' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_73_35\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_73_35'>Select your age group<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_35' id='input_73_35' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Under 18' >Under 18<\/option><option value='18-24' >18-24<\/option><option value='25-34' >25-34<\/option><option value='35-44' >35-44<\/option><option value='45-54' >45-54<\/option><option value='55-64' >55-64<\/option><option value='65 or above' >65 or above<\/option><option value='Prefer not to answer' >Prefer not to answer<\/option><\/select><\/div><\/div><div id=\"field_73_37\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_73_37'>Your primary language<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_73_37' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='American Sign Language' >American Sign Language<\/option><option value='Chinese' >Chinese<\/option><option value='English' >English<\/option><option value='Haitian Creole' >Haitian Creole<\/option><option value='Portuguese' >Portuguese<\/option><option value='Spanish' >Spanish<\/option><option value='Vietnamese' >Vietnamese<\/option><option value='Korean' >Korean<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_73_40\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_73_40'>What is your race?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_73_40' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='African-American\/Black' >African-American\/Black<\/option><option value='American Indian\/Native American\/Alaskan Native (*Specify)' >American Indian\/Native American\/Alaskan Native (*Specify)<\/option><option value='Asian' >Asian<\/option><option value='Native Hawaiian\/Pacific Islander (*Specify)' >Native Hawaiian\/Pacific Islander (*Specify)<\/option><option value='Caucasian\/White' >Caucasian\/White<\/option><option value='Two or more races' >Two or more races<\/option><option value='Undisclosed' >Undisclosed<\/option><\/select><\/div><\/div><div id=\"field_73_41\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_73_41'>What is your ethnicity?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_73_41' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Hispanic or Latino' >Hispanic or Latino<\/option><option value='Not Hispanic or Latino' >Not Hispanic or Latino<\/option><option value='Undisclosed' >Undisclosed<\/option><\/select><\/div><\/div><div id=\"field_73_45\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_73_45'>Select your child&#039;s age group<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_45' id='input_73_45' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='0-3' >0-3<\/option><option value='3-6' >3-6<\/option><option value='7-13' >7-13<\/option><option value='14-21' >14-21<\/option><option value='22-26' >22-26<\/option><\/select><\/div><\/div><div id=\"field_73_36\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_73_36'>Does your child have any developmental disability?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_73_36' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Do not know' >Do not know<\/option><\/select><\/div><\/div><div id=\"field_73_47\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_73_47'>Does your child have any behavioral health needs?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_47' id='input_73_47' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Do not know' >Do not know<\/option><\/select><\/div><\/div><div id=\"field_73_46\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_73_46'>Is your child medically complex?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_46' id='input_73_46' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Do not know' >Do not know<\/option><\/select><\/div><\/div><fieldset id=\"field_73_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is this your first time receiving respite?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_73_25'>\n\t\t\t<div class='gchoice gchoice_73_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_73_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_25_0' id='label_73_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_73_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_25_1' id='label_73_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Unsure'  id='choice_73_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_25_2' id='label_73_25_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_25_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Does not apply'  id='choice_73_25_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_25_3' id='label_73_25_3' class='gform-field-label gform-field-label--type-inline'>Does not apply<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_73_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is this your first time providing respite?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_73_28'>\n\t\t\t<div class='gchoice gchoice_73_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Yes'  id='choice_73_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_28_0' id='label_73_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_73_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_28_1' id='label_73_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Unsure'  id='choice_73_28_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_28_2' id='label_73_28_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_28_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Does not apply'  id='choice_73_28_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_28_3' id='label_73_28_3' class='gform-field-label gform-field-label--type-inline'>Does not apply<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_73_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-eleven-twelfths gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Since the match connection has been made, how many hours of respite have you received?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_73_26'>The way our program defines respite is anything that helps you experience a break from caregiving. Some of our caregivers may have had the caregiver they were matched with come to their home and engage their child in play or other activity while they run an errand or take time to exercise, rest or do something else they enjoy. Others may have swapped school drop off and pick up duties with their match which also freed up some time in their day. Yet others exchanged time in the community with their children and received as well as provided a break from caregiving. Please reflect on your match experience and let us know approximately how many hours of respite you have received since you have been matched.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_73_26'>\n\t\t\t<div class='gchoice gchoice_73_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='0'  id='choice_73_26_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_73_26\"   \/>\n\t\t\t\t\t<label for='choice_73_26_0' id='label_73_26_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='1-5'  id='choice_73_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_26_1' id='label_73_26_1' class='gform-field-label gform-field-label--type-inline'>1-5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_26_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='5-10'  id='choice_73_26_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_26_2' id='label_73_26_2' class='gform-field-label gform-field-label--type-inline'>5-10<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_26_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='10-15'  id='choice_73_26_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_26_3' id='label_73_26_3' class='gform-field-label gform-field-label--type-inline'>10-15<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_26_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='15-20'  id='choice_73_26_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_26_4' id='label_73_26_4' class='gform-field-label gform-field-label--type-inline'>15-20<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_26_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='more than 20'  id='choice_73_26_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_26_5' id='label_73_26_5' class='gform-field-label gform-field-label--type-inline'>more than 20<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_73_38\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_73_38'>How satisfied are you with your respite experience?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_73_38' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Very Satisfied' >Very Satisfied<\/option><option value='Satisfied' >Satisfied<\/option><option value='Neutral' >Neutral<\/option><option value='Unsatisfied' >Unsatisfied<\/option><option value='Very Unsatisfied' >Very Unsatisfied<\/option><\/select><\/div><\/div><fieldset id=\"field_73_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you accessed the C2C Learning Platform: LearnWorlds?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_73_42'>\n\t\t\t<div class='gchoice gchoice_73_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_73_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_42_0' id='label_73_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_73_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_42_1' id='label_73_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_73_42_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Unsure'  id='choice_73_42_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_73_42_2' id='label_73_42_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_73_43\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_73_43'>How satisfied are you with the use of the learning platform?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_73_43' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Very Satisfied' >Very Satisfied<\/option><option value='Satisfied' >Satisfied<\/option><option value='Neutral' >Neutral<\/option><option value='Unsatisfied' >Unsatisfied<\/option><option value='Very Unsatisfied' >Very Unsatisfied<\/option><\/select><\/div><\/div><div id=\"field_73_44\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_73_44'>How satisfied are you with the content of the learning platform?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_44' id='input_73_44' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Very Satisfied' >Very Satisfied<\/option><option value='Satisfied' >Satisfied<\/option><option value='Neutral' >Neutral<\/option><option value='Unsatisfied' >Unsatisfied<\/option><option value='Very Unsatisfied' >Very Unsatisfied<\/option><\/select><\/div><\/div><div 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the Caregiver to Caregiver Respite Network.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_73_39' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_73_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I give permission to the Federation for Children with Special Needs to share my feedback about the program in their marketing and outreach materials.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container 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