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* 1. On a scale from 1 to 5, with 1 being the least stressed and 5 being the most stressed, how stressed are you?

  1 Least Stressed 2 3 4 5 Most stressed
How stressed are you?

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* 2. Tell Us Your Zip or Postal Code

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* 3. For whom do you care? Check as many as appropriate.

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* 4. How long have you been in a personal caregiving situation?

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* 5. Which race/ethnicity best describes you? (Please choose only one.)

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* 6. What is your gender identity?

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* 7. Do you also work? Please check as many as apply.

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* 8. How would you describe your financial situation prior to caregiving?

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* 9. How would you describe your financial situation today?

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* 10. Which benefits and programs does your caree receive?

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* 11. How would you describe your savings for your future?

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* 12. How has your caregiving experience impacted your ability to save for your future? Check as many as apply.

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* 13. How much of your own money do you use to pay for caregiving experiences on an annual basis?

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* 14. For which caregiving expenses do you pay? (Check all that apply.)

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* 15. What do you need that you can’t afford? (Check all that apply.)

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* 16. How comfortable do you feel about your ability to pay for your own future care?

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* 17. What would help you most? Please check as many as appropriate.

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* 18. What would change for you if you had enough money to pay for today’s needs and save enough for your future?

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* 19. What is your experience trying to find help for yourself and your caree?

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* 20. Please share any experiences about the financial impact of your caregiving experience.

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* 21. Would you like to receive updates from us on our campaign to create financial security for family caregivers? If so, please share your email address, below.

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* 22. Would you or your organization like to help with our initiative? Please share your email address, below, so we can be in touch.

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