Caregiver Survey

Are you a caregiver?
Do you help someone with their healthcare appointments or medications, manage their finances, or help regularly with daily tasks like chores, cooking or shopping? If so, you are a caregiver.

Thank you for your interest in our Caregiver Survey! Unfortunately, you don't meet the criteria for this survey, but we hope you'll join us for future opportunities.

Caregiver Survey
What is your relationship to the person receiving care?
Are you the only person providing care for the care recipient?
How long have you provided care for the care recipient?
How often do you provide care for the care recipient?
Are you providing care for any other individuals?
What is their relationship to you? (check all that apply)
Are you providing care to someone with Alzheimer’s disease or related disorders with neurological and organic brain dysfunction?
If there anyone you can call in an emergency to fill in for you as a caregiver?
Has a health condition[s] affected your ability to provide care?
During the last 12 months, have you been hospitalized anytime while being a caregiver?
Are you working outside of the home?
Has working outside of the home affected your ability to provide care?
Do you provide assistance to a care recipient with any of the following activities? Check all that apply.
Are you aware of caregiver resources currently available to you within the community?
Have you received caregiver support services in the past?
If you are looking for services now, what prompted your search? Check all that apply.
As a caregiver, is your sleep disturbed?
For example: person I care for wanders at night; needs assistance; I can't sleep.
Do you feel caregiving is inconvenient?
For example: helping takes a lot of time ; it’s a long drive over to help.
Is caregiving a physical strain?
For example: lifting in or out of a chair/bed/toilet.
Is caregiving confining to you?
For example: restricts my free time; I cannot go places I enjoy.
Have there been family adjustments since becoming a caregiver?
For example: helping has disrupted my routine; there is no privacy; family arguments.
Do you feel caregiving has caused changes in personal plans?
For example: I could not go on vacation; I cannot participate in activities that I enjoy.
Are there other demands on your time?
For example: other family member need me; work.
Have there been emotional adjustments related to caregiving?
For example: arguments with family about caregiving; anger; sadness.
Do you find that some behavior is upsetting?
For example: person cared for has memory issues; outbursts.
Is it upsetting to find the person you care for has changed so much from his/her former self?
For example: he/she is a different person than he/she used to be; unable to do things.
Have you experienced work adjustments?
For example: I have to take time off for caregiving duties; adjusting schedules; unable to work.
Is caregiving causing a financial strain?
For example: I use personal finances for caregiving; unsure about future financial situation.
Do you find yourself completely overwhelmed by caregiving?
For example: I worry about the person I care for; I have concerns for my future.