Caregiver Program Support and Assessment

Question Title

* 1. Are you still the caregiver for [CARE RECIPIENT'S NAME] or [someone 60 years of age or older?]

Question Title

* 2. What is your relationship to [CARE RECIPIENT'S NAME]? Are you his or her...

Question Title

* 3. I'm going to read you several activities that some people need help with. When [CARE RECIPIENT'S NAME] performs or is involved in these activities, how often do you help with...

  All the time of Most of the time Sometimes Rarely or Never
Activities like dressing, eating, bathing, or getting to the bathroom? Would you say...
Medical needs such as taking medicine or changing bandages? Would you say...
Keeping track of bills, checks, or other financial matters?
Preparing meals, doing laundry, or cleaning the house?
Going shopping or to the doctor's office?
Arranging for care or services provided by others?

Question Title

* 4. Have you received the following services as a caregiver?

  Yes No
Respite Care (period of rest for you)
Information or referral to caregiver services
Caregiver training/education/ counseling/support group
Supplemental services (home modifications, assistive tech, etc.)

Question Title

* 5. To what extent did the following services help you as a caregiver?

  They helped a lot They helped a little They didn't help They made things worse I didn't receive this service
Respite Care (period of rest for you)
Information or referral to caregiver services
Caregiver training/education/ counseling/support group
Supplemental services (home modifications, assistive tech, etc.)

Question Title

* 6. Of the caregiver services provided, which one service was the most helpful?

Question Title

* 7. Have these caregiver services enabled you to provide care for [CARE RECIPIENT'S NAME] for a longer time than would have been possible without these services? Would you say...

Question Title

* 8. Overall, how would you rate the caregiver support services that have been provided?

T