Let’s get started First Name Last Name Phone Number Email Address Next Which state do you live in? AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming What is your zip code? BackNext What best describes your situation? Caring for someoneBeing cared for by someoneNeither Do you live with the person you are taking care of? YESNO BackNext What best describes your situation? BathingDressingWalkingGetting up the stairs or out of the bedToiletingSupervision with completing any other tasks Do you live with the person you are taking care of? YESNO Back
