Fairfield Cares, Inc
Caregiver Home Health Survey

Thanks to The Greater Jefferson County Foundation, City of Fairfield L.O.S.T. grant, and private donors for funding this survey.

Fairfield Cares is a non-profit dedicated to building a more responsive system of home health care that supports well-being and independence for senior citizens and those of all ages who need health, social, and other services in order to remain safely in their homes for as long as possible in Jefferson County.

The purpose of this survey is to identify the resources needed by those who have been providing help of any kind for an elderly and/or a temporarily or permanently disabled person in order to help that individual remain safely in their homes for as long as possible.

Thank you for taking the time to fill out this survey. Your responses will help identify needs and gaps to be addressed as we join together and build resources to help solve this problem.

WHO SHOULD COMPLETE THIS SURVEY

Spouses, partners, other family members, friends, RNs, CNAs, physical therapists, and anyone else -- paid or unpaid – who provides or has provided help to a Jefferson County resident with a chronic illness and/or a temporary or permanent condition so they could remain safely at home as long as possible.

Complete this survey if you provide -- or have provided within the past five (5) years -- ANY of the following:

In-home nursing and/or nursing assistance.
Physical therapy.
Medication management.
Housekeeping.
Meal preparation and/or delivery.
Grocery shopping &/or errands.
Bathing &/or toileting.
Managing finances, paying bills.
Minor appliance repairs.
Minor house repairs & maintenance.
Installing safety devices.
Yard & property maintenance.
Childcare.
Transportation to appointments.
Companionship.
Helping access physical, social, &/or mental health services.

CONFIDENTIALITY
Your responses are automatically anonymous. You will not be identified unless you complete the form at the end.

IF YOU NEED HELP TO COMPLETE THIS SURVEY
Send your name, phone number, and your question to:
surveyhelp@lisco.com

We’ll get back to you as soon as we can.

IF YOU COMPLETED A PAPER COPY OF THIS SURVEY
Put your survey in the box at one of these locations:

Fairfield Public Library, 104 W. Adams Street - On rear of counter.
Fairfield City Hall, 118 S. Main Street - Inside 1st door.
Fairfield Universal Therapy, 1401 S. Main Street - On table left of front desk.
Revelations (Revs) Health Center, 114 N. Main Street

Question Title

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

Yes

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* 2. Do you provide caregiving:

In your home

In patient’s home

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* 3. Relationship of caregiver to patient

Spouse

Family member other than spouse

Friend

Other non-related caregiver

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

1 - 2

3 – 5

6 - 7

Other (please specify)

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

Yes

If yes, what are your limitations?

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

Yes

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

My health insurance

My client/patient's homeowners insurance

I paid out of pocket

NA - I did not require any treatment or down time

NA - I have not been injured while caregiving

Other (please specify)

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

Yes

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* 9. Have you fully recovered from the injury?

Yes

If No, are you permanently impaired due to 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?

Yes

Other (please specify)

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

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* 12. Rate your health.

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

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* 13. Are you a paid caregiver?

Yes

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

Patient/client

Patient/client's family

Patient/client's insurance (long-term care insurance - not primary)

A caregiving agency

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

Yes

NA - I am a paid caregiver

If Yes, please note your source of income, such as from other employment, Social Security, or retirement funds:

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

Reduced work hours

Quit job

NA - I did not reduce my work hours or quit my job

Other (please specify)

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

Yes

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

The past week

The past month

Past 3 months

Past 6 months

Past year

I never get a break

NA - I am not a 24/7 caregiver

Other (please specify)

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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?

Yes

If yes, do you need help finding resources to help pay for respite care?

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

Yes

I don't know

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

Yes

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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	In Person Weekly	In Person Bi-weekly	In Person Monthly	In Person N/A
Zoom	Zoom Weekly	Zoom Bi-weekly	Zoom Monthly	Zoom N/A

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

Yes

If No, would you like to receive counseling?

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

Health Insurance

Professional Liability Insurance

General Liability Insurance

Malpractice Insurance

Car Insurance - if providing transportation in own vehicle

Homeowners Insurance - if providing care in own home

No insurance

Other (please specify)

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

Yes

If Yes, have you received special training to help you with the special needs of your patient?

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

Supervision

Medication management - pill set up, refill prescriptions, administer meds, etc.

Bathing

Dressing

Toileting or continence care

Housekeeping

Meal preparation

Assistance with feeding

Shopping or errands

Transportation - to/from medical appointments or errands

Assistance with a home exercise program

Pay bills

Assistance with communication - such as using the phone or computer

Other (please specify)

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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?

Yes

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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?

Delivered meals (Meals on Wheels, Mom's Meals, Sister's Meals etc.)

Transportation (10-15 Transit)

Milestones Area Agency on Aging

I am not aware of any of these resources

Other (please specify)

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

Yes

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* 31. Have you taken any Caregiver training courses?

Yes

If Yes, please specify:

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

Yes

NA - I have taken caregiver training courses

If Yes, would you prefer online or in person?

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

Yes

If yes, do you know where and how to access the resources?

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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?

Yes

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

Yes

I'm not sure

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

Yes

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

Yes

If Yes, what language do you need help translating?

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

Yes

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

My own vehicle

My client's vehicle

Client's family vehicle

NA - I don't provide transportation

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

Great: The home has proper heating and air-conditioning, the roof, floors, and windows are in good condition, and appliances are in good working order.

Good: Needs some minor improvements - such as appliances could use upgraded, windows sealed to prevent drafts but otherwise adequate and livable

Needs Improvement: Major repairs such as fixing a leaking roof, floors, replacing more than 1 window or door, water heater, and/or anything else that constitutes a major expense.

Inadequate: Lacks appropriate heating/cooling systems, appliances are not in reliable working order

Unfit: Lacks running water and/or electricity

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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.

Client's retirement funds

Client's family

Client's Social Security funds

Government programs - food stamps, housing assistance

Client has long term care insurance

Other (please specify)

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

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Fairfield Cares, IncCaregiver Home Health Survey

Question Title

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

Question Title

* 2. Do you provide caregiving:

Question Title

* 3. Relationship of caregiver to patient

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 9. Have you fully recovered from the injury?

Question Title

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

Question Title

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

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* 12. Rate your health.

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* 13. Are you a paid caregiver?

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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?

Question Title

* 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.

Question Title

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

Question Title

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

Question Title

* 31. Have you taken any Caregiver training courses?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

Fairfield Cares, Inc
Caregiver Home Health Survey