This survey will help FACE (Faith Action for Community Equity) determine the extent and need

for Long Term Care/Disability Insurance in Hawaii. Thank you very much for your participation
in gathering much needed data to help us all prepare for the future needs of our loved ones.
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Please write in your answers: Age: _____ Ethnicity__________ Location of

home__________________
Please checkmark the name of your organization: ____AARP; ____Chamber of
Commerce ____Geriatric Fellows _____HGEA ____HMA _____HMSA
____HSTA ____HSTA-R ____ILWU ____Kokua Council ____Nurses Union
(dont know nurses union acronym) _____Other (please write in the name of your
organization)_______________________________________

Please checkmark what you feel is the best answer:

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Have you cared for someone? Yes_____
No_____
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Please answer this question only if it applies to you: How long have you cared for
someone? _____1-5 yrs; _____5-10 yrs; _____10+ yrs
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Do you anticipate caring for someone? Yes_____ No_____
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If you have provided care for someone, please check all that apply:
_____Drove the person to a doctors appointment
_____Made meals for the person
_____Assisted in feeding the person
_____Assisted in bathing and toileting the person
_____Assisted in dressing the person
_____Administered medication to the person
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Have you completed an Advanced Care Directive? _____Yes______No
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How much do you think nursing homes cost per month?
_____$5,000
_____$8,000 - 10,000
_____$15,000 _____$20,000
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How much do you think day care costs per month?
_____$5,000 _____$8,000 - 10,000 _____$15,000 _____$20,000
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Do you have LTC/DI? (Long Term Care/Disability Insurance) _____Yes _____No
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Does your family have a LTC/DI plan for you? _____Yes _____No
Do your parents have LTC/DI for themselves: _____Yes _____No
_____Parents deceased
Who do you think pays for nursing home or day care cost?
_____Medicare _____Medicaid _____Patient _____Patients Family
Town/Community where you live:_______________________________________