Male     Female 

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?  

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?

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?

  Yes   No 

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?

  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?

 Additional Comments: