Review of Domiciliary Short Breaks

Section 1 - Background Information

NOTE: This questionnaire will be anonymous; where you want to make comments or give additional information, do not use your own name of that of the person you care for.

Question Title

* 1. How long have you been in a caring role?

Less than a year

1-2 years

2-4 years

4-7 years

More than 7 years

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* 2. What relationship do you have to the person you care for?

Husband/Wife

Son/Daughter

Father/Mother-In-Law

Aunt/Uncle

Friend/Neighbour

Other (please specify)

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* 3. Please indicate your gender

Male

Female

Other Designation

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* 4. Can you please indicate your age group?

16-18 years

19-64 years

65-74 years

75-84 years

85+ years

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* 5. What Council area does the person you care for live in?

Question Title

* 6. What is the main reason why that person needs care?

Learning Disability

Physical Disability

Mental Ill-Health

Age/Infirmity

Dementia

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* 7. What circumstances led you to needing the short break? Please tick below; you can tick more than one.

Changes in your own health

Increased caring required

Family crisis

Work commitments

Feeling under pressure

Other (please specify)