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Fairfield Cares is a local non-profit dedicated to creating a community environment that supports people thriving from cradle to grave. To this end, we are working to build partnerships and a more responsive, compassionate system of care that promotes well-being and independence for senior citizens and those of all ages with special needs for health care, social support, and other services in our community.
 
WHO SHOULD COMPLETE THE SURVEY:
Caregivers who provide skilled and/or unskilled services to assist the elderly and/or those with a temporary or permanent disability or chronic illness with their daily living activities.
 
Your answers to the following questions will provide data to help us build partnerships and resources in Jefferson County.
 
CONFIDENTIALITY:
All responses to the survey are automatically confidential and compiled in a manner that prevents the identification of individual respondents. Note: If you want to receive information about resources and projects being developed related to caregiving, please enter your contact information at the end of the survey. 

For additional assistance with completing this survey contact

Vanessa Pohren at:

Phone: 641-451-9978
Email: vanessapohren.ffc@gmail.com

The survey is also on the website: www.fairfieldcares.net
Funded by The Greater Jefferson County Foundation & Fairfield’s L.O.S.T. grants & private donations.

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* 1. Are you 65 years of age or older?

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* 2. Do you provide caregiving:

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* 3. Relationship of caregiver to patient

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* 4. How many days per week do you provide Caregiving?

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* 5. Do you have any health limitations that affect your ability to provide caregiving?

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* 6. Have you been injured while caregiving (such as hurting your back, pulling a muscle, etc.)?

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* 7. If you needed treatment for the injury, who covered the cost?

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* 8. Did you lose any wages due to the injury and/or recovery restrictions?

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* 9. Have you fully recovered from the injury?

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* 10. Does the injury now interfere with your ability to work in the same way you worked before the injury?

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* 11. Rate the level of stress you are under related to your job/role as a caregiver.

  No Stress Somewhat Stressed Moderately Stressed Extremely Stressed
Financial Stress:
Emotional Stress:

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* 12. Rate your health.

  Poor (Nutrition)/None Needs Improvement Average/Adequate Well Balanced (Nutrition)/Meets Healthy Recommendations
Nutrition:
Weekly Exercise:
Weekly Time Outdoor:
Weekly Relaxation Time:

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* 13. Are you a paid caregiver?

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* 14. If you receive payment for caregiving, who pays you?

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* 15. If you are unpaid, do you have another source of income?

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* 16. Did you reduce your work hours or quit your job to provide care for a friend or family member?

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* 17. Are you struggling to make ends meet financially due to being a Caregiver?

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* 18. For 24/7 caregivers, have you had a break for more than 24 hours/one day from caregiving in:

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* 19. If available, would you be interested in temporary support or an alternative living arrangement for your patient to give you a period of respite from caregiving?

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* 20. If there were an adult daycare center available, would your patient qualify for that service?

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* 21. If available, would you be interested in participating in a support group for caregivers?

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* 22. If you are interested in a support group for caregivers, please note your preferences

  Weekly Bi-weekly Monthly N/A
In Person
Zoom

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* 23. Are you receiving counseling to help cope with caregiving along with other responsibilities?

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* 24. Do you have insurance? Check all that apply

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* 25. Does your patient have memory issues such as dementia or Alzheimer’s?

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* 26. What type of service or assistance do you provide? Check all that apply.

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* 27. Do you have all the skills you need to safely and adequately provide the care needed for your patient or loved one to remain in their home?

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* 28. If not, please list skills and/or knowledge you want/need to learn, such as medication management, wound care/prevention, CPR/basic first aid, proper body mechanics, etc.

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* 29. Are you aware of the following services and resources available for your patient/loved one?

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* 30. Do you know the eligibility requirements, where, and how to obtain those or any other services/resources?

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* 31. Have you taken any Caregiver training courses?

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* 32. If you have not taken any caregiver training courses, would you like to?

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* 33. Are you aware of services and resources for caregivers?

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* 34. Do you feel you are a good match with your level of training and expertise with the level of care your patient needs?

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* 35. Do you plan to continue being a caregiver?

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* 36. If you moved to the United States, did you do so with the intention of becoming a caregiver?

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* 37. Do you or your patient need assistance with translation services?

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* 38. Do you provide care for more than 1 person?

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* 39. If you provide transportation for your client/loved one, whose vehicle do you use?

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* 40. What are the living conditions of the home in which you provide care?

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* 41. How are the financial needs of your client/loved one met? Such as rent, utilities, prescriptions, groceries, etc. Check all that apply.

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* 42. Please enter your name and contact information if you would like to be contacted regarding any future education, support, or information related to caregiving.  **Contact info is not linked with answers to previous questions to maintain confidentiality. Contact info will not be shared or sold to any other entity.**

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