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 care 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.
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 take 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 . 
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 

The next questions ask about other services —these do not include help connecting to 

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 the 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 

21a. 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. In 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, which 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 children I care for 

3 Respite care 

4 Caregiver training, education, counseling, or support groups 

5 Supplemental services 

22b. If YES, what were 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

b. Feel less physical stress? 1 2

c. Feel less emotional stress? 1 2

d. Feel less worried about money? 1 2

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. Do 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. Are 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: