Fillable Form Approved: SECTION 1. BACKGROUND (Administration for Community Living)

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Form Approved: SECTION 1. BACKGROUND (Administration for Community Living)

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Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. The OMB control number for this project is xxxx-xxxx. Public reporting burden for
this collection of information is estimated to average 5 minutes per respondent, per year, including the time to review instructions. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to [title], [address, city, state, zip].
SECTION 1. BACKGROUND
1. Have you received any caregiver support services within the last 12 months from
For example, these may include .
1
Yes
PLEASE CONTINUE
2
No
Thank you for your time, but the focus of this survey is on people who
have received caregiver support services within the last 12 months.
2. How long have you been receiving caregiver support services?
1
Less than 6 months
2
Between 6 months and 1 year
3
More than 1 year
3. In your role as a caregiver, how many people do you care for?
1
1
2
2
3
3
4
4 or more
3a. If you car
e for a child/children under 18, how many children do you care for?
1
1
2
2
3
3
4
4 or more
This section asks about your background, and the person you provide care for.
For the following questions, think about the person with whom you spend the most time
as a caregiver.
[Insert name of Program]
[Insert short list of
the types of services
offered]
Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
2
4. What is your relationship to the person you care for?
The person I care for is my:
1
Spouse or partner
2
Parent
3
Grandparent
4
Brother or sister
5
Aunt or uncle
6
Adult son or daughter/Son-in-law or daughter-in-law
7
Child under 18 years old such as a grandchild, great niece or great nephew
9
Other relative not mentioned above (please describe): ____________
10
Someone else not mentioned above (please describe): ___________
5. How old is the person you care for? __________
6. Where does
the person you care for live?
1
Lives alone
2
Lives with a spouse or partner who is not me
3
Lives with me
4
Lives with a family member other than me
5
Other (please describe): ______________________
7. Please t
ake a moment to think about all of the care that the person you care for needs.
Are you the sole provider of care for that person?
1
Yes, I am the sole caregiver
2
No, other people help provide care
7a. If you checked “No”, how many other people help provide care to that
person?
1
One other person helps provide care
2
Two other people help provide care
3
Three or more people help provide care
8. How many hours in an average week do you spend providing care for this person?
Hours: ___________
Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
3
9. Do you currently have a job for which you receive pay?
1
Yes, I work full time for wages
2
Yes, I work part time for wages
3
No, I am retired
4
No, I do not currently work a job for wages
SECTION 2. CAREGIVER SUPPORT SERVICES
10. In the last 12 months, has someone from the program given you information to connect
you to any services and/or resources, including services or supports for the person you
care for?
1
Yes
2
No
10a. If YES, how easy to understand was the information?
1
Very easy to understand
2
Somewhat easy to understand
3
Not very easy to understand
4
Not at all easy to understand
11. As a result
of getting this information were you able to connect to the services or
resources you needed?
1
Yes, I got all of the services and/or resources I needed
2
Yes, I got some of the services/resources I needed
3
No, I did not get any of the services and/or resources I needed
12. In the last 12 months, have you received a break while someone takes your place as the
caregiver? This service is sometimes called “respite care.”
1
Yes
2
No
The questions in this section ask about the caregiver support you may have received
in the last 12 months from .
[Insert Program Name]
Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
4
12a. If YES, which type(s) of respite care do you usually receive in a given
month? (CHECK ALL THAT APPLY)
1
In-home respite, where someone comes to the home to take care of the
person you care for
2
Daytime care for an adult or a grandchild, where the person you care for
goes to a program during the day
3
Overnight respite care in a facility outside the home (e.g., nursing home,
childcare facility, etc.)
4
Overnight respite care in the home
5
Other (please describe): _____________________________
13. How many hours of respite care do you usually receive in a month?
Hours:__________
1
I do not receive this service
14. Overall, how would you rate the respite care you received in the last 12 months?
1
Very Good
3
Good
4
Poor
5
Very Poor
6
I did not receive this service in the last 12 months
15. Is the number of hours of respite care you receive each month enough?
1
Yes, it is enough but more would be better
2
Yes, it is enough
3
No, it is not enough
4
I do not receive this service
16. How many hours of respite care would you like to have in a month?
Hours: _________
17. In the last 12 months, have you received any caregiver training or education, including
counseling or support groups, to help you make decisions or solve problems in your role
as caregiver?
1
Yes
2
No
Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
5
17a. If YES, which type(s) of service did you receive? (CHECK ALL THAT
APPLY)
1
Caregiver education or training, such as classroom or Internet courses
2
Individual counseling to assist with your specific caregiver situation
3
Caregiver support groups
4
Other (please describe): ___________________________
17b. If YES, did any of the training, education, counseling or support group
services talk about dementia or Alzheimer’s?
1
Yes
2
No
18. Overall, how would you rate the caregiver training, education, counseling, or support
group services you received in the last 12 months?
1
Very Good
2
Good
3
Poor
4
Very Poor
5
I did not receive this service in the last 12 months
19. In the last 12 months, has the program provided you with any supplemental services to
help you provide care? Supplemental services may include transportation; nutritional
supplements, such as Boost or Ensure; devices, such as potty seats, canes or walkers; a
personal emergency response system; stipends; etc.?
1
Yes
2
No
services/resources, or respite care, or education/training, or counseling/support groups—
that you as the caregiver, or the person you care for, have received in the last 12 months.
Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
6
19a. If YES, which supplemental services did you receive? (CHECK ALL THAT APPLY)
1
Devices (e.g., canes, walkers, potty seats)
2
Case management (i.e., coordination and care management)
3
Congregate meals (e.g., meals at a center)
4
Home-delivered meals
5
Home health aide (not respite)
5
Chore assistance (e.g., light housekeeping, laundry, chopping wood)
6
Home modification or adaptive equipment (e.g., grab bars, ramps, bath chair)
7
Incontinence supplies (e.g., Depends, Poise)
8
Legal assistance
9
Medical devices (e.g., nebulizer, hospital bed, wheelchair)
10
Nutritional supplements (e.g., Ensure, Boost)
11
Personal emergency response system
12
Emotional or mental health services for the person you care for
13
Transportation
14
Emergency supplies for children
15
Stipends
16
Other (please describe): _______________________
19b. If YOU DID NOT receive any supplemental services in the last 12 months, which
supplemental services do you think would be helpful to receive?
(CHECK ALL THAT APPLY)
1
Devices (e.g., canes, walkers, potty seats)
2
Case management (i.e., coordination and care management)
3
Congregate meals (e.g., meals at a center)
4
Home-delivered meals
5
Home health aide (not respite)
5
Chore assistance (e.g., light housekeeping, laundry, chopping wood)
6
Home modification or adaptive equipment (e.g., grab bars, ramps, bath chair)
7
Incontinence supplies (e.g., Depends, Poise)
8
Legal assistance
9
Medical devices (e.g., nebulizer, hospital bed, wheelchair)
10
Nutritional supplements (e.g., Ensure, Boost)
11
Personal emergency response system
12
Emotional or mental health services for the person you care for
13
Transportation
14
Emergency supplies for children
15
Stipends
16
Other (please describe): _______________________
Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
7
20. Overall, how would you rate the supplemental services you received in the last 12
months?
1
Very Good
2
Good
3
Poor
4
Very Poor
5
I did not receive this service in the last 12 months
21. In t
he last 12 months, have you received a voucher, cash, or individual budget from the
program that allows you to purchase goods or services for the person(s) you care for? By
“voucher or budget payment,” we mean that you were given an allowance where you can
decide by yourself what to buy or whom to hire.
1
Yes
2
No
2
1a. If YES, how did you use the voucher, cash, or individual budget?
(CHECK ALL THAT APPLY)
1
Purchase supplies
2
Pay for a service (e.g., transportation, meals)
3
Hire a person to assist with caregiving activities or tasks
4
Pay for Respite Services
5
Other (please describe): ________________
6
Don’t know
22. I
n the last 12 months, was there a time when you could not receive the services you
needed?
1
Yes
2
No
Now, the next questions ask you to think back to all of the caregiver support services you
have received (e.g., help connecting to services/resources, respite care,
education/training, counseling/support groups, and supplemental service such as
transportation, nutritional supplements, assistive devices, such as canes or walkers,
stipends) —that you as the caregiver, or the person you care for, have received in the last
12 months.
Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
8
22a. If YES, whi
ch services were you unable to receive?
(CHECK ALL THAT APPLY)
1
Help connecting to services and resources for the adult I care for
2
Help connecting to services and resources for childr
en I care for
3
Respite care
4
Caregiver training, education, counseling, or support groups
5
Supplemental services
22b. If YES, what w
ere the reason(s) you were not able to receive the service(s)?
(CHECK ALL THAT APPLY).
1
Service was not available in my area
2
There was a waitlist to receive the service
3
Unable to schedule at a convenient time
4
Provider cancelled or did not show up
5
Lack of transportation to access service
6
Other (please describe): ____________________
7
Don’t know
SECTION 3. OUTCOMES OF CAREGIVER SUPPORT SERVICES
23. As a result of the
caregiver support services do you:
(CHECK ONE BOX ON EACH LINE)
Yes
No
a. Have more time for personal activities?
1 2
2
b. Feel less physical stress?
1
c. Feel less emotional stress?
1 2
2
d. Feel less worried about money?
1
e. Have a better understanding of how to get needed services for
the person you care for?
1 2
f. Feel more confident in providing care to the person you care
for?
1 2
Not
Applicable
g. [If caring for an adult] Know more about the condition or illness
of the adult person you care for?
1 2 3
h. [If caring for grandchildren] Know more about the needs of the
child/children you care for?
1 2 3
i. [If employed] Have fewer conflicts with your job?
1 2 3
The questions in this section ask about how the caregiver support experiences have
affected your life.
Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
9
24. Have the caregiver support services you’ve received helped you to provide care for a
longer period of time than would have been possible without these services?
1
Yes, definitely
2
Yes, probably
3
No, probably not
4
No, definitely not
5
Don’t know
25. Would the person you care for have been able to continue to live in the community
(outside of a nursing home or other care facility) if you had not received caregiver support
services?
1
Yes, definitely
2
Yes, probably
3
No, probably not
4
No, definitely not
5
Don’t know
6
The person I care for does not live in his/her own home
26. To what extent have the caregiver support services improved your quality of life?
1
Very much
2
Somewhat
3
Very little
4
Not at all
5
Don’t know
SECTION 4. CAREGIVER HEALTH
27. In your experience as a caregiver, how important is each of the following?
(CHECK ONE BOX ON EACH LINE)
Not at all
Important
Not
Important
Somewhat
Important
Very
Important
a. Helping the person I care for live at home
1
2
3
4
b. Spending time with someone I care about
1
2
3
4
c. Feeling a sense of accomplishment
1
2
3
4
d. Satisfaction that my care and attention are
received
1
2
3
4
e. Being appreciated
1
2
3
4
f. Fulfilling a duty
1
2
3
4
g. Other, please specify: ________________
1 2 3 4
The questions in this section ask about some potential benefits and challenges you may
have when providing care to the person you care for.
Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
10
28. D
o you have any kind of health problem, physical condition, or disability that affects the
amount or type of care that you can provide?
1
Yes
2
No
3
Don’t know
29. How physically difficult would you say it is for you to provide care to the person you care
for?
1
Not at all difficult
2
A little difficult
3
Somewhat difficult
4
Very difficult
30. How emotionally difficult would you say it is for you to provide care to the person you
care for?
1
Not at all difficult
2
A little difficult
3
Somewhat difficult
4
Very difficult
31. How financially difficult would you say it is for you to provide care to the person you care
for?
1
Not at all difficult
2
A little difficult
3
Somewhat difficult
4
Very difficult
32. Has your caregiving ever interfered with your employment?
1
Yes, but I continue to work
2
Yes, I took a leave of absence but went back to work
3
Yes, I reduced my hours as a result
4
Yes, I retired early as a result
5
Yes, I quit work as a result
6
Yes, I lost my job as a result
7
No
8
I was never employed while providing care
Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
11
SECTION 5. A LITTLE ABOUT YOU!
33. What is your age? _______
34. What is your sex?
1
Male
2
Female
3
Other
35. What is your race? (CHECK ALL THAT APPLY)
1
White
2
American Indian or Alaska Native
3
Asian
4
Black or African American
5
Native Hawaiian or Other Pacific Islander
36. Ar
e you of Hispanic, Latino/a, or of Spanish Origin?
1
Yes
2
No
37. What
is your marital or relationship status?
1
Married
2
Partnered
3
Widowed
4
Divorced
5
Separated
6
Never married
38. In general, how would you rate your overall health?
1
Excellent
2
Very good
3
Good
4
Fair
5
Poor
Thank you very much for completing this survey. Please return it in the envelope
provided to:
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Form Approved: SECTION 1. BACKGROUND (Administration for Community Living)

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Completed 7 August 2020

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