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Caregiver Survey
Step
1
of
5
20%
Are you a caregiver?
*
Do you help someone with their healthcare appointments or medications, manage their finances, or help regularly with daily tasks like chores, cooking or shopping? If so, you are a caregiver.
Yes
No
Thank you for your interest in our Caregiver Survey! Unfortunately, you don't meet the criteria for this survey, but we hope you'll join us for future opportunities.
What is your relationship to the person receiving care?
*
Wife
Husband
Sister
Brother
Daughter/Daughter-in-law
Son/Son-in-law
Domestic partner/Civil union
Other relative
Non-relative
Are you the only person providing care for the care recipient?
*
Yes
No
How long have you provided care for the care recipient?
*
--Please Select--
Less than a year
1-3 years
4-6 years
7-9 years
10-12 years
13-15 years
More than 15 years
How often do you provide care for the care recipient?
*
Daily
Weekly
Monthly
Less than once per month
Are you providing care for any other individuals?
*
Yes
No
What is their relationship to you? (check all that apply)
*
Spouse
Child under 18
Sibling
Adult child with a disability
Neighbor
Other
If other, please specify:
*
Are you providing care to someone with Alzheimer’s disease or related disorders with neurological and organic brain dysfunction?
*
Yes
No
If there anyone you can call in an emergency to fill in for you as a caregiver?
*
Yes
No
Has a health condition[s] affected your ability to provide care?
*
Yes
No
During the last 12 months, have you been hospitalized anytime while being a caregiver?
*
Yes
No
Are you working outside of the home?
*
Yes
No
Has working outside of the home affected your ability to provide care?
*
Yes
No
Do you provide assistance to a care recipient with any of the following activities? Check all that apply.
*
Personal care tasks
Homemaker chores
Transportation
Managing finances
Health care
Supervision
Emotional support
Other
If other, please describe:
*
Are you aware of caregiver resources currently available to you within the community?
*
Yes
No
Have you received caregiver support services in the past?
*
Yes
No
If yes, what type of resources have you taken advantage of?
*
(i.e. in-home caregivers, Meals on Wheels, support groups, respite care, etc.)
If you are looking for services now, what prompted your search? Check all that apply.
*
Care recipient condition changed
Caregiver health changed
Family circumstances changed
Family/friend referred
Professional/health care provider referred
Other
Not applicable
If other, please specify:
*
Understanding your caregiver experience
Here are some things that other caregivers have found to be difficult. Please rate based on your caregiving experience. Even though your situation may be different than the example given, the item could still apply to you.
My sleep is disturbed.
For example: person I care for wanders at night; needs assistance; I can't sleep.
Yes, on a regular basis
Yes, sometimes
No
Caregiving is inconvenient.
For example: helping takes a lot of time ; it’s a long drive over to help.
Yes, on a regular basis
Yes, sometimes
No
Caregiving is a physical strain.
For example: lifting in or out of a chair/bed/toilet.
Yes, on a regular basis
Yes, sometimes
No
Caregiving is confining.
For example: restricts my free time; I cannot go places I enjoy.
Yes, on a regular basis
Yes, sometimes
No
There have been family adjustments.
For example: helping has disrupted my routine; there is no privacy; family arguments.
Yes, on a regular basis
Yes, sometimes
No
There have been changes in personal plans.
For example: I could not go on vacation; I cannot participate in activities that I enjoy.
Yes, on a regular basis
Yes, sometimes
No
There have been other demands on my time.
For example: other family member need me; work.
Yes, on a regular basis
Yes, sometimes
No
There have been emotional adjustments.
For example: arguments with family about caregiving; anger; sadness.
Yes, on a regular basis
Yes, sometimes
No
Some behavior is upsetting.
For example: person cared for has memory issues; outbursts.
Yes, on a regular basis
Yes, sometimes
No
It is upsetting to find the person I care for has changed so much from his/her former self.
For example: he/she is a different person than he/she used to be; unable to do things.
Yes, on a regular basis
Yes, sometimes
No
There have been work adjustments.
For example: I have to take time off for caregiving duties; adjusting schedules; unable to work.
Yes, on a regular basis
Yes, sometimes
No
Caregiving is a financial strain.
For example: I use personal finances for caregiving; unsure about future financial situation.
Yes, on a regular basis
Yes, sometimes
No
I feel completely overwhelmed.
For example: I worry about the person I care for; I have concerns for my future.
Yes, on a regular basis
Yes, sometimes
No
