If you have now, ever have, or anticipate taking care of one or more loved ones (family members, friend or neighbor), we invite you to take this survey to help us to better support you (and others like you) in our community. This information will be used to determine what resources and services are needed in the community.  
  
Your individual response is confidential and will be combined with everyone who completes the survey.  
  
If you know of other people who support loved ones, please feel free to share this survey with them.  

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* 1. What county are you from?

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* 2. What is your age?

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* 3. What is your gender?

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* 4. What is your experience in taking care of a loved one?

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* 5. What county does your loved one live in?

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* 6. What is the age of your loved one(s) (or age they were when you took care of them) – (You can provide more than one age if you care for more than one person.)

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* 7. What is the relationship of the loved one to you?

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* 8. Do you live with the loved one that you care for?

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* 9. Does your loved one have any disabilities not brought on by age?

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* 10. Does your loved one have any chronic or pre-existing health conditions?

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* 11. Which of the following ways do you care for your loved one? (Choose all that apply)

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* 12. How many hours a week (typically) do you provide support to your loved one?

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* 13. If you have used professional services for your loved one, what has made them most useful to you? (If not applicable, please enter N/A)

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* 14. If you have used professional services for your loved one, in what ways were they not useful to you? (If not applicable, please enter N/A)

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* 15. What 2 services do you really wish were available for your loved one?

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* 16. Other than the help that you directly provide for your loved one, does your loved one receive assistance from any services for any of the following? (check all that apply)

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* 17. Of those you selected in #16, please list whom you receive services from:

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* 18. If you have not received any help for caring for your loved one, would you consider getting help?

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* 19. What are the top three activities that you do that cause you the most stress? (choose three)

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* 20. What would be helpful to you in addressing the three activities identified in #18? (information? Direct help? Someone to talk to?, etc.)

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* 21. If help was available for your areas of concern, would you want to know more about that help?

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* 22. How do you currently become aware of resources and services that are available for your loved one? Check all that apply.

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* 23. How would you like to learn about resources and services available for your loved one? Check all that apply.

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* 24. Would you participate in on-line educational programs?

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* 25. Do you have the technology/ability to go on-line to view educational programs or find information?

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* 26. What educational programs would you be interested in?

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* 27. What would prevent you from participating in on-line educational programs?

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* 28. If you could give advice to someone who is suddenly facing taking care of a loved one, what would you tell them?

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* 29. Is there anything else you would like to share regarding your experience in taking care of loved ones?

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* 30. How has COVID-19 directly impacted you negatively regarding your care of loved ones?

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* 31. If you would like information regarding caregiver services in the future, please submit your contact information below. Your contact information will not be tied to your responses in anyway.

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