With older adult(s)
With other adult
ARE YOU A CAREGIVER?
For the purpose of this survey, a
Caregiver is considered either someone who assists another, usually an older person, in various tasks such as transportation, meal preparation and medication management or is concerned about a loved one.
If yes, answer questions 1-13, if not
skip to question 16.
1. How long have you been a Caregiver?
2. How many people do you currently care for over the age of 60?
3 or more
3. If you are the caregiver of someone over the age of 60, are you also a caregiver for children under the age of 18?
no If yes, how many?
4. How aware are you of your community resources?
Not aware at all
5. As a caregiver, what types of community resources do you or have you utilized?
6. What resources would you like to see offered through your company?
7. What is the best way to receive information through your company?
8. Have you ever considered quitting your job due to your caregiving duties?
9. What is your general level of stress since you have been a caregiver?
10. Is there a strain on family relations secondary to caregiving concerns?
11. Have you used your company's FMLA program to provide caregiving services?
12. Have you ever had to leave work early or come in late in order to perform your caregiving duties?
If yes, on average how many times in one year?
1 - 4
5 - 10
10 - 15
13. Have you ever had to take off work in order to perform your caregiving duties?
1 - 2
3 - 6
7 - 10
14. Do you feel comfortable discussing your caregiving issues with your supervisor?
15. How would you rate your overall morale at work?
If you would like your Care Manager to contact you immediately, please put your name, email address and/or telephone number in the comment section.
If you are currently NOT a caregiver, please answer the following questions:
16. Have you been a caregiver in the past?
No If no, skip to question 19.
17. Did you feel you had adequate resources to fulfill your caregiving duties?
18. How would you rate your past level of stress related to your caregiving experience?
19. Do you foresee yourself being a caregiver in the future?
20. How aware are you of community resources for older adults?
Not aware at all
21. What resources would you like to see offered through your company?