Caregiver Survey

What is your relationship to CARE RECIPIENT:

spouse
child/child-in-law sibling
other relative
friend/neighbor
professional
care manager
How long have you provided most of the care?

less than 6 months
6 to 12 months
13 to 24 months
25 months to 5 years
more than 5 years
What is your age?

18 to 30 years
31 to 40 years
41 to 50 years
51 to 60 years
61 to 70 years
71 years or over
What is your gender?

female
male
What is your marital status?

single
married
widowed
other
Which of the following categories best describes your race?

White
African-American
American Indian or Alaskan Native
Asian Hispanic
What is your employment status:

works full-time
works part-time
What is the highest grade in school you completed?

high school graduate (diploma or GED)
some college or post high school training
Associate degree
Bachelor’s degree
graduate degree
During the past week, about how many hours total did you help the CARE RECIPIENT with Eating, bathing, dressing or helping with toilet function

 

During the past week, about how many hours total did you help the CARE RECIPIENT with Meal preparation, laundry or light housework

 

During the past week, about how many hours total did you help the CARE RECIPIENT with Providing transportation to appointments and/or shopping

 

During the past week, about how many hours total did you help the CARE RECIPIENT with Legal matters, banking or money matters

 

The CARE RECIPIENT lives:

 in your home
 in their own home/apartment
 in an assisted living facility
 in a nursing home
 other (please explain below)
The CARE RECIPIENT lives (other explanation):

 

Is the CARE RECIEVER or the CAREGIVER receiving companion or friendly visitors?

 

Is the CARE RECIEVER or the CAREGIVER receiving transportation services?

 

Is the CARE RECIEVER or the CAREGIVER receiving supervision?

 

Is the CARE RECIEVER or the CAREGIVER receiving services from a case management/service coordination?

 

Is the CARE RECIEVER or the CAREGIVER receiving homemaker services?

 

Is the CARE RECIEVER or the CAREGIVER using support groups?

 

Is the CARE RECIEVER or the CAREGIVER receiving chore services?

 

Is the CAREGIVER receiving services from a caregiver training program?

 

Is the CARE RECIEVER or the CAREGIVER receiving personal care services?

 

Is the CARE RECIEVER or the CAREGIVER receiving psychological counseling?

 

Is the CARE RECIEVER or the CAREGIVER receiving home health services?

 

Is the CARE RECIEVER or the CAREGIVER receiving group meals/home delivered meals?

 

Is the CARE RECIEVER or the CAREGIVER receiving services from an adult daycare center?

 

Is the CARE RECIEVER or the CAREGIVER receiving respite in own home, someone else’s home, nursing home, or other location?

 

Is the CARE RECIEVER or the CAREGIVER receiving other services? (please list below)?

 

Other services received:

 

CAREGIVER/CARE RECIPIENT support - Do you need help with personal care services?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with transportation services?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with personal finance?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with adult day care?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with congregate meals?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with home delivered meals?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with social contacts?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with housekeeping?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with shopping/errands?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with services from a health professional?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with case management/service coordination?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with respite?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with support group?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with psychological counseling?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with caregiver training?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with chore services?

 

CAREGIVER/CARE RECIPIENT support - Do you need help with other service? (please list below)

 

Other services assistance needed:

 

Would you access case management services if they were available?

 

Additional Comments:

 

If you would like us to contact you please provide us with a name and phone number or e-mail address.
Name:
Phone:
E-Mail: