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CAREGIVER NEEDS ASSESSMENT SURVEY

Some people provide regular unpaid care or assistance to a family member or friend who has a health condition, long-term illness or disability. Care is provided to their family member or friend to maintain an independent lifestyle. If you have provided unpaid care in the past six months please complete the survey below.
1.Your gender:
2.Your age:
3.Your race/ethnicity:
4.Your marital status: 
5.Your zip code:
6.What is the relationship of the person you provided unpaid care for in the past six months?
7.What is the age of the person you provided care for?
8.What county does the person you care for live in?
9.Does the person you care for live with you or in their own home?
10.How long have you been a caregiver?
11.What kind of assistance do you provide? (Please check all that apply.)
12.Overall, approximately how many hours do you spend caregiving or assisting the person in a  typical week?
13.Which of these concerns have you experienced as a result of your caregiving responsibilities? (Please rate each item listed below.)
Very Concerned
Somewhat Concerned
Not Concerned or N/A
Finding trained & reliable home care providers
Having enough money to pay for care
Understanding government programs such as Medicare, Medicaid, or SSI
Availability of legal options
Receiving cooperation & assistance from other family members and friends
Ensuring the care recipient's safety
Finding transportation
Communicating with healthcare professionals
Planning for end of life care
Balancing other family responsibilities
Dealing with difficult behaviors of the care recipient
Modifying home to meet care requirements
Meeting my personal needs such as exercise, work schedule, social activities, sleep
14.Has caregiving caused you:
Yes
No
Physical/health changes
Financial strain
Emotional strain or stress
15.How much help have you received from family and friends?
16.Has your employment status changed because of caregiving responsibilities? (Check all that apply.)
17.Approximately how many full or partial scheduled workdays did you miss during the past 6 months due to your caregiving responsibilities?
18.Which of the following resources/services do you currently use or would you find useful? (Please respond to all items listed below.)
Currently Use
Would Use
Would Not Use
Workshops/seminars on older adult care issues
Workshops/seminars on taking care of myself
Internet references on caregiving
Caregiver support group
Legal consultation
Assistance with Medicare, Medicaid, SSI
Assistance in determining long term care options
Money management services
Care management
Home adaptation (grab bars,wheelchair ramp, handrails, etc.)
Personal emergency response system
Adult day care/respite services
Chore/housekeeping services
Home care provided by an agency
Home delivered meals
Transportation services
19.If any of the above were checked "Would Use", why do you currently not use them? (Please check all that apply.)
20.Thank you very much for completing the survey! If you would like to speak with someone from Region IV Area Agency on aging about available resources/services please call our Info-Line at (800) 654-2810 or provide your name and telephone number below and/or any additional comments.
Current Progress,
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