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? (Required.)

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 (Required.)

Male

Female

Other Designation

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4. Can you please indicate your age group? (Required.)

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? (Required.)

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6. What is the main reason why that person needs care? (Required.)

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. (Required.)

Changes in your own health

Increased caring required

Family crisis

Work commitments

Feeling under pressure

Other (please specify)

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

Question Title

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

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* 3. Please indicate your gender (Required.)

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* 4. Can you please indicate your age group? (Required.)

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

Question Title

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

Question Title

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

1. How long have you been in a caring role? (Required.)

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

3. Please indicate your gender (Required.)

4. Can you please indicate your age group? (Required.)

5. What Council area does the person you care for live in? (Required.)

6. What is the main reason why that person needs care? (Required.)

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