Needs of Caregivers Evaluation
County (Please write in)
Gender: (Please check one) FEMALE MALE
Age Range: (Please check one)
18-29 30-39 40-49 50-59 60-69 70-79 80-89
Marital status: (Please check one or write in)
MARRIED SINGLE DIVORCED OTHER
Race: (Please check one or write in)
Alaskan Native American Indian African American
Filipino Hawaiian Japanese
Asian Pacific Islander White
LATINO Other
Occupation: (Please check one or write in)
GOVERNMENT PROFESSIONAL MANAGEMENT EDUCATION
LABOR INDUSTRY TECHNICAL SALES/SERVICE CLERICAL
OTHER
Employment status: (Please check one)
EMPLOYED FULL TIME EMPLOYED PART TIME SELF EMPLOYED
HOMEMAKER UNEMPLOYED RETIRED
Income range: (Please check one)
$0-$9,999.00 $10,000.00-$19,999.00 $20,000.00-$29,999.00
$30,000.00-$39,999.00 $40,000.00-$49,999.00 $50,000.00-$59,999.00
$60,000.00+
What is your highest level of educational obtainment? (Please check one)
JUNIOR HIGH HIGH SCHOOL SOME COLLEGE CERTIFICATE
ASSOCIATES DEGREE BACHELORS DEGREE MASTERS DEGREE DOCTORATE
1. How did you become a care giver FOR AN ADULT?
2. How long have you been providing care for an adult?
0-6 MONTHS 7 MONTHS-1 YEAR 1-2 YEARS OTHER
3. do you also care for children?
yes No If yes how many?
4. What is your relationship to the adult you care for?
CHILD PARENT SIBLING OTHER
5. why did you become a caregiver?
6. HOW MANY ADULTS DO YOU CARE FOR?
1 2 3 4 or More
7. hOW MANY HOURS DO YOU PROVIDE CARE PER WEEK?
1-3 4 -7 8 or More
8. Do you have any previous CAREGIVING experience?
YES NO If so, how long AND WHO HAVE YOU CARED FOR?
9. Please check all of the following social and emotional supports you have available?
(PLEASE CHECK ALL THAT APPLY)
FAMILY FRIEND(S) FAITH BASED ORGANIZATION(S) CLUB(S)
COMMUNITY ORGANIZATION(S) OCCUPATIONAL MEDICAL
PSYCHOLOGICAL/PSYCHIATRIC GOVERNMENTAL SPIRITUAL
RECOVERY GROUP(S) OTHER
10. WHAT SERVICES ARE YOU CURRENTLY USING TO HELP YOU PROVIDE CARE?
ADULT DAY CARE
ADULT DAY HEALTH
AREA AGENCY ON AGING/ COUNCIL ON AGING
HOME HEALTH
HOMEMAKER SERVICES
HOSPICE
IN HOME CARE GIVERS
LIFELINE
MEALS ON WHEALS/ HOME DELIVERED MEALS
OCCUPATIONAL THERAPY
OXYGEN/ DURABLE MEDICAL EQUIPMENT
PHYSICAL THERAPY
RESPITE CARE
SENIOR MEALSITE
SPEECH THERAPY
TRANSPORTATION
OTHER (PLEASE WRITE IN)
PLEASE RATE EACH SERVICE IN RELATION TO YOUR NEEDS.
11. ADULT DAY CARE
EXTREMELY POOR BELOW AVERAGE AVERAGE ABOVE AVERAGE EXCELLENT
Not applicable to me
12. ADULT DAY HEALTH
13. AREA AGENCY ON AGING/ COUNCIL ON AGING
14. HOME HEALTH
15. HOME MAKER SERVICES
16. HOSPICE
17. IN HOME CARE GIVERS
18. LIFELINE
19. MEALS ON WHEALS / HOME DELIVERED MEALS
20. OCCUPATIONAL THERAPY
21. OXYGEN/ DURABLE MEDICAL EQUIPMENT
22. PHYSICAL THERAPY
23. RESPITE CARE
24. SENIOR MEAL SITE
25. SPEECH THERAPY
26. TRANSPORTATION
27. OTHER
28. WHAT SERVICES HAVE WORKED WELL FOR YOU IN THE PAST?
29. WHAT WAS YOUR REASON FOR DISCONTINUING PREVIOUS SERVICES?
30. WHAT OTHER SERVICES WOULD YOU FIND HELPFUL?
31. DO YOU RECEIVE COMPENSATION FOR ANY OF THE CARE YOU PROVIDE?
YES NO IF YES HOW ADEQUATE IS THE COMPENSATION?
EXTREMELY INADEQUATE BELOW ADEQUATE ADEQUATE ABOVE ADEQUATE EXCELLENT
32. DO YOU ACCESS SERVICES THROUGH MEDICAID?
YES NO IF YES HOW HELPFUL HAVE YOU FOUND IT?
Please feel free to add any additional comments or important information:
Thank you for your participation!