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Post- Caregiver Respite Funding Survey
1.
Who provided the service you requested?
2.
Have you felt a reduction in caregiving stress because of having Caregiver-GAP funds?
Yes
No
Please explain.
3.
Regarding the use of Caregiver Respite funds, do you feel …? (Check all that apply)
More comfortable accepting help from others
More comfortable having respite workers provide support at home
More comfortable with respite support outside of home
That respite workers have provided competent care
That I should have used respite support earlier
Other (Please Describe)
4.
How much do you agree with the following statement: I used my respite plan to do something I enjoyed and felt that the respite was “time well spent”?
Completely Disagree
Somewhat Disagree
Somewhat Agree
Completely Agree
5.
Has respite allowed you to spend time on the various activities that you enjoy (e.g., going to religious services, socializing with others, going out for a meal) or spending time on hobbies or activities you like to enjoy alone (e.g., reading or gardening)?
Yes
No
6.
Has the use of respite made a positive difference to you and your family?
Yes
No
7.
If given the opportunity, would you use respite services again?
Yes
No
8.
I feel …. (Check all that apply)
A sense of relief that someone else is available to provide care
More confident about asking for help or assistance with care
More balance in my life in giving care and also trying to take care of myself
I have regained some enjoyable activities I had lost in caregiving
I am taking better care of my own health (physically and emotionally) through respite
Getting respite breaks was worth my time and effort in arranging them
The quality of the care during respite was competent and adequate for our needs
I am able to continue in my caregiving role for the foreseeable future
That the care recipient has benefited from the interaction with the respite worker/provider
More confident about finding/identifying/selecting a respite provider
More confident about preparing/training a respite provider to give care
More confident about how to use respite breaks effectively
More convinced of the benefits received from respite
9.
BEFORE receiving respite, how “stressed” were you as a result of caring for your family member?
Low Stress
Moderate Stress
Very Stressed
10.
1. NOW that you have received respite services, how “stressed” are you as a result of caring for your family member?
Low Stress
Moderate Stress
Very Stressed
11.
Do you have someone now you can call on in an emergency to fill in for you as a caregiver?
Yes
No
12.
Please indicate your overall level of satisfaction with the respite services you recently received
Completely Dissatisfied
Somewhat Dissatisfied
Somewhat Satisfied
Completely Satisfied
13.
Is there anything else that would help you in your caregiver role?
14.
What is your 5-digit zip code?
15.
Age Category
under 60
60 - 64
65 - 74
74 - 84
85+
16.
Gender
Female
Male
Female to Male / Transgender Male
Male to Female / Transgender Female
Decline to Answer
Other (please specify)
17.
Ethnicity
Not Hispanic or Latino
Hispanic or Latino
18.
Your Race
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Another race
19.
What is your relationship with the person receiving care?
Wife
Husband
Domestic Partner, including Civil Union
Daughter / Daughter-in-Law
Son / Son-in-Law
Grandmother
Grandfather
Mother
Father
Other Relative
Non-Relative
