Informed Consent for Family/Caregiver Needs Assessment Survey

About the Research:

The goal of this study is to assess the needs of individuals serving as a caregiver of a child from another family member within the Central Public Health District (Kennebec and Somerset Counties). We will use the data to develop messaging and support strategies to include in healthcare staff training and community based education and outreach.

Your participation is your choice. You may opt out at any time without penalty.

This survey should take 5-10 minutes to complete.

Risks and Benefits:

This survey poses little risk to you because it is anonymous. The benefits of participation to be acknowledgement of caregivers needs. In addition, the data will contribute to professional understanding of this population’s needs and help ongoing efforts to provide support services to individuals providing care to children of family members with a substance use disorder.  


Confidentiality of Records:

These surveys are anonymous. Your responses will be summarized with all the survey respondents. They will not be reported individually. MaineGeneral staff will keep physical copies of survey responses in locked and secured offices until they are destroyed after the data is analyzed.


If you have questions about the research and the research subjects’ rights, call LeeAnna Lavoie, Director of Prevention Services, at 207-626-1620.

If there is a research-related injury, please call the Steve Diaz, MD, Chief Medical Officer, IRB chairperson, at 207-621-9305.

Copy of Informed Consent and Questions Answered:

If you want a copy of this informed consent, we will give one to you. If you have other questions before you complete the survey, please contact Kristina Stewart at or call 207-626-7354.

This product was supported by the Federal office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under grant #GA1RH33518.  The information, conclusions and opinions expressed in this product are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.

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* 1. What is your gender?

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* 2. What is your age group?

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* 3. Which of these do you identify as?

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* 4. Do you identify as?

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* 5. How many children are you raising?

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* 6. What ages is/are the child(ren)? Check all that apply as well as the number of children in each category.

  1 2 3 4 5+
0-2 years
3-5 years
6-8 years
9-11 years
12-14 years
15-17 years
18 years or older

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* 7. How long have you been raising the child(ren)?

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* 8. What legal status do you have with the child(ren) living in your home?

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* 9. Do you have this/these child(ren) in your home as a result of parental substance use?

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* 10. What are the greatest concerns you have in raising children at this time? Please check all that apply.

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