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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.

FOR HELP IN COMPLETING THIS SURVEY
Call 641-451-9978

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

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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 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.**

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