Caregiver Wellness Needs Assessment Survey

About You: the Caregiver

Briefly asks participants about basic demographic info

Question Title

* 1. Your Age (in Years)

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Question Title

* 2. Your Gender

Male

Female

Prefer not to answer

Question Title

* 3. Your Current Relationship Status

Married / Common Law

Widow

Divorced

Separated

Single

Prefer not to answer

Question Title

* 4. Aside from caregiving, your main activity in the past year

working at a paid job or business

looking for paid work

going to school

caring for family members, such as grandkids; household work

retired

Other (please specify)

Question Title

* 5. Your Religious Background (optional)

Christianity

Hinduism

Islam

None

Prefer not to answer

Other (please specify)

Question Title

* 6. Your ethno-cultural background (optional)

European

South Asian

Chinese

African

Filipino

West Asian

Arab

Latin American

Aboriginal

Southeast Asian

Korean

Japanese

Other (please specify)

Question Title

* 7. Annual / Yearly Household Income (optional)

Under $15,000

Between $15,000 and $29,999

Between $30,000 and $49,999

Between $50,000 and $74,999

Between $75,000 and $99,999

Between $100,000 and $150,000

Over $150,000

Caregiver Wellness Needs Assessment Survey

About You: the Caregiver

Question Title

* 1. Your Age (in Years)

Question Title

* 2. Your Gender

Question Title

* 3. Your Current Relationship Status

Question Title

* 4. Aside from caregiving, your main activity in the past year

Question Title

* 5. Your Religious Background (optional)

Question Title

* 6. Your ethno-cultural background (optional)

Question Title

* 7. Annual / Yearly Household Income (optional)

Question Title

* 8. Postal Code of Your Current Residence