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Employee Survey

Here is your opportunity to get your voice heard and needs met about your new employee benefit, the Caring Workplace. We are designing this program to meet your needs, at your business. Be part of this exciting new project by giving us your thoughts, ideas, needs and background information.

In order to provide the best services to you, the employee, please complete the following survey even if you are currently not caring for an older adult. This information will be used to help make this program a success for your entire company.

All information is strictly confidential and your name is not needed.

Name:

Gender:

Male     Female 

Age:

under 30
31-39
40-44
45-49

50-54
55-59
60-65
65+

Marital Status:

Single
Married
Divorced 

Separated
Widowed

Job Status:

Full Time
Part Time

PRN
Temp

Shift:

Day
Evening
Night

Split Shift
Swing Shift

Job Classification:

Clerical/Support
Management
Production

Technical
Professional
Other

Person(s) in Household:

Live alone
With Children 
   1     2     3   4     >5
With older adult(s)
With spouse
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?  

< 6 months
6-12 months
1-3 years

3-5 years
> 5 years 

2.  How many people do you currently care for over the age of 60?

1       2     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?

Yes  no     If yes, how many?

4.  How aware are you of your community resources?

Extremely aware   Somewhat aware   
Not aware at all  

5.  As a caregiver, what types of community resources do you or have you utilized?

At Home services
Eldercare Management
Adult Day Care
Support Groups

Housing Options
In-depth assessment
Counseling
Educational seminars
Other

6.  What resources would you like to see offered through your company?

Eldercare Management
Support Groups
In-depth Assessment
Housing Options

Counseling
Resource Information
Educational Seminars
Other

7.  What is the best way to receive information through your company?

E-mail
Website
Flyers
Brown bag lunch

Presentations
One-on-one
Other

8.  Have you ever considered quitting your job due to your caregiving duties?

  Yes   No 

9.  What is your general level of stress since you have been a caregiver?

Extremely stressed
Moderately stressed

Minimally stressed
Not stressed

10.  Is there a strain on family relations secondary to caregiving concerns?

  Yes   No 

11.  Have you used your company's FMLA program to provide caregiving services?

  Yes   No

12.  Have you ever had to leave work early or come in late in order to perform your caregiving duties?

  Yes   No

If yes, on average how many times in one year?

1 - 4      5 - 10     10 - 15     >15

13.  Have you ever had to take off work in order to perform your caregiving duties?

  Yes   No  

1 - 2      3 - 6     7 - 10     >10

14.  Do you feel comfortable discussing your caregiving issues with your supervisor?

  Extremely comfortable   Somewhat comfortable
  Uncomfortable 

15.  How would you rate your overall morale at work?

  Excellent   Good   Fair   Poor  

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.

Additional Comments:

 

If you are currently NOT a caregiver, please answer the following questions:

16.  Have you been a caregiver in the past?

Yes   No       If no, skip to question 19.

17.  Did you feel you had adequate resources to fulfill your caregiving duties?

Yes   No  

18.  How would you rate your past level of stress related to your caregiving experience?

Extremely stressful     Moderately stressful
Minimally stressful      Not stressful

19.  Do you foresee yourself being a caregiver in the future?

Yes   No 

20.  How aware are you of community resources for older adults?

Extremely aware        Somewhat aware   
Not aware at all  

21.  What resources would you like to see offered through your company?

Eldercare Management
Support Groups
In-depth Assessment
Housing Options

Counseling
Resource Information
Educational Seminars
Other

 

 Additional Comments: