SUA Resource Library: 

Uniform Satisfaction Survey Materials 
Foreword 

In 2012, the Administration for Community Living (ACL), an operating division of the US 

Department of Health and Human Services, began a comprehensive evaluation of its National 

Family Caregiver Support Program (NFCSP). This was the first comprehensive federal evaluation 

of the NFCSP, which serves over 800,000 family caregivers annually. The NFCSP evaluation has 

three broad goals to benefit policy and program decision-making: 

1. Collect and analyze information on program processes and site operations; 

Evaluate program efficiency and cost issues for approaches best suited to specific 

contexts; and 

Evaluate effectiveness of the program’s contribution to family caregivers in terms of 

maintaining their health and well-being, improving their caregiving skills, and 

avoiding or delaying institutional care of the care recipient. 

2.

3.

As part of the evaluation survey, State Units on Aging (SUAs) were asked to submit relevant 

documents if they answered ‘yes’ to any of the following five questions: 

 Do you have a statewide task force, commission or coalition specifically to examine 

family caregiver issues? 

Have community needs assessments for caregiver support services been conducted? 

Does your state have a standardized caregiver assessment? 

Does your SUA conduct routine programmatic monitoring of the NFCSP program? 

Do you use a uniform caregiver satisfaction survey across all AAAs? 









ACL received assessment tools and grouped them into the following categories: 

1. Community Assessment Materials 

General Customer Satisfaction Survey Materials 

Grandparent Assessment Materials 

High-Level Administrative Materials 

Program Monitoring Materials 

State Caregiver Assessments 

State Care Recipient Assessments 

Task Force Materials 

Uniform Satisfaction Materials 

Other Materials 

2.

3.

4.

5.

6.

7.

8.

9.

10.

While ACL does not specifically endorse these tools, we are sharing them because they may be 

helpful to other programs. For more information on the NFCSP please go to: 

http://www.aoa.acl.gov/. For more information on the evaluation of the NFCSP please go to: 

http://www.aoa.acl.gov/Program_Results/Program_Evaluation.aspx
Uniform Satisfaction Survey Materials 

Connecticut Satisfaction Survey: Southwest ................................................................................................ 3 

Connecticut Satisfaction Survey: West ......................................................................................................... 5 

Connecticut Satisfaction Survey: East ........................................................................................................... 6 

Connecticut Satisfaction Survey: South Central ........................................................................................... 9 

Connecticut Satisfaction Survey: North Central ......................................................................................... 11

Georgia Caregiver Satisfaction Survey ........................................................................................................ 13 

Georgia Services and Satisfaction Survey ................................................................................................... 15

Kansas Satisfaction Survey .......................................................................................................................... 18

Massachusetts Caregiver Satisfaction Survey ............................................................................................. 22

Minnesota Satisfaction Outcomes Survey .................................................................................................. 24

Oregon Satisfaction Survey ......................................................................................................................... 26

Vermont Dementia Respite Caregiver Survey ............................................................................................ 28

2
[Type text Page 1 

National Family Caregiver Support Program Caregiver Quality Assurance 

Survey 

We are always looking to improve the quality of our program and we can 

not accomplish this without you. We appreciate your response to the 

survey. 

1. Overall, how satisfied are you with the services that you and/or your family 

member receive? 

Would you say ... 

 Very satisfied 

Somewhat satisfied 

Somewhat dissatisfied 

Very dissatisfied 







Comments: 

2. To what extent do the services that you and/or family member receive help 

you to be a better caregiver? Would you say ... 

 They help a lot 

They help a little 

They do not help 

They make things worse 







Comments: 

3. Have the services enabled you to provide care for your family member for 

a longer time than would have been possible without these services? Would 

you say 

 Yes, definitely 

Yes, I think so 

No, I do not think so 

No, definitely not 







Comments: 

Connecticut Satisfaction Survey: Southwest 3
[Type text Page 2 

Background Questions (Optional) 

 4. How long have you been caring for your family member? _____Months _____Years 

5. What is the age of the family member? ________ 

6. What is the gender of the family member? ______Female ________Male 

7. What is your age? _______ 

8. What is your gender? ____Female _____Male 

9. Do you have any kind of physical condition or disability that affects the kind of care that 

you can provide? 

____Yes ____No

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________ 

10. Ethnicity/Race : 

 € American Indian or Alaska Native 

 Black or African American 

 Native Hawaiian or other Pacific Islander

Other (Specify Below) 

 € Asian 

 € € Hispanic or Latino 

 € € White, Not of Hispanic Origin 

 € € Not Collected 

 

11.As a caregiver, do you have needs that are not presently being met? Please use the 

space below or on the back to explain. 

 

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________ 

12.What can be done to improve the National Family Caregiver Support program, services and 

overall support to the caregiver? Please use the space below or on the back to explain. 

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________ 

13.If you would like us to contact you, please fill in the sections below: 

 Name ________________________________ P h o n e _ _ _ _ _ _ _ _ _ _ _ _ _ _ 

T h a n k y o u f o r t a k i n g t h e t i m e t o c o m p l e t e t h i s s u r v e y . Y o u r f e e d b a c k i s 

v e r y i m p o r t a n t t o u s . 

Connecticut Satisfaction Survey: Southwest 4
NFCSP CLIENT SATISFACTION SURVEY 2014

The Western Connecticut Area Agency on Aging (WCAAA) has been pleased to be able to give you 

assistance under the National Family Caregiver Support Program (NFCSP). Please take a moment to 

fill out this survey; your feedback will help us improve the program and enable us to provide services 

effectively to other families. You do not need to put your name on this survey. 

1. How did you hear about the benefits offered through the National Family Caregiver Support 

Program by the WCAAA? 

 __Friend 

Newspaper 

Newsletter 

Other: 

__

__

__Radio/TV 

Brochure 

Infoline 

__

__

__Hospital 

Visiting nurse 

Case manager 

__

__

__Municipal Agent 

__Doctor 

__

_____________________________________________________________________________

2. Was the WCAAA staff person courteous and helpful? ___yes ___no 

3. Was the information about the program made clear to you? ___yes ___no 

4. Were services arranged in a timely manner? ___yes ___no 

5. Were you were satisfied with the services you received?

describe any problems you may have had: 

 ___yes ___no Please 

6. How have the services you’ve been receiving helped you? 

7. How have the services you’ve been receiving helped your caregiver? 

8. Do you have suggestions for improving the program? 

9. As a caregiver, please check workshops that would be of interest to you: 

__ Legal issues: living wills, advance healthcare directives, power of attorney, etc. 

__ Paying for in-home care __ How to identify depression, delirium, or dementia 

__ Information on: __ Alzheimer’s __ other diseases of aging (which ones?): 

_____________________

__ Home safety, minor modifications, and assistive medical equipment 

__ Death and dying __ Other topics? 

____________________________________________________

10. What time of day would be best for you to attend a workshop? Are there circumstances that 

would prevent you from attending at some times of the day? 

11. Other comments? (Use the back of the sheet if necessary.) 

Thank you for taking time to fill out this survey! (Please return by September 20, 2013) 

Please return to WCAAA, 84 Progress Lane, Waterbury CT 06705 

For more information or if you have questions, call Marissa or Sandy at 1-800-994-9422 or 203-757-5449.

Connecticut Satisfaction Survey: West 5
Senior Resources - Agency on Aging 

National Family Caregiver Support Program 

The National Family Caregiver Support Program is meant to be a brief, temporary respite for you, the 

caregiver, by reducing your stress so you may continue to care for your loved one. 

2013 – 14 Caregiver Consumer Satisfaction Questionnaire 

Please help us improve our program by answering some questions about the services you have received. 

We are interested in your honest opinions, whether they are positive or negative. Please answer all of the 

questions. We also welcome your comments and suggestions. Thank you very much; we really appreciate 

your help. 

Please Circle your answer:

How would you rate the quality of service you have received?

Excellent Good Fair Poor 

Did you get the kind of service you wanted?

No, definitely No, not really Yes, generally Yes, definitely 

To what extent has our program met your needs? 

Almost all of my 

needs have been met 

Most of my needs

have been met 

 Only a few of my 

 needs have been met

None of my needs

have been met 

If a friend were in need of similar help, would you recommend our program to him/her? 

No, definitely not No, I don’t think so Yes, I think so Yes, definitely 

How satisfied are you with the amount of help you have received?

Quite dissatisfied Indifferent or mildly

dissatisfied 

 Mostly satisfied Very satisfied 

 

Have the services you received helped you deal more effectively with your concerns? 

Yes, they helped 

a great deal 

Yes, they helped No, they really 

didn’t help

No, they seemed to

 make things worse 

In an overall general sense, how satisfied are you with the service you have received? 

Very satisfied Mostly satisfied Indifferent or 

mildly dissatisfied 

Quite dissatisfied 

 

If you were to seek help again, would you come back to our program?

No, definitely not No, I don’t think so Yes, I think so Yes definitely 

Connecticut Satisfaction Survey: East 6
Senior Resources - Agency on Aging 

National Family Caregiver Support Program 

Once this form is received, your request will be placed on a waiting list. This does not guarantee 

acceptance on this program; however, it does allow for a review of need. Please PRINT and fill out 

completely (an incomplete reconsideration request will delay placement on the waiting list). 

CAREGIVER RECONSIDERATION FORM 2014-2015 

(October 2014 – September 2015) 

Name of Caregiver: ________________________ Name of Care Recipient: _____________________ 

Please indicate your service requests. 

Service Agency Currently Providing Service 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

How is the care recipient able to function now? Please indicate with an “x” the level of assistance needed in the 

following areas. 

DAILY ACTIVITIES

Personal Hygiene: bathing, grooming and

oral care

Dressing: physically dress self and make 

appropriate clothing decisions

Eating: feed oneself

Maintain Continence: the mental/physical 

ability to use bathroom

Transferring: moving oneself from seated 

to standing and getting in/out bed

INDEPENDENT

 YES OR NO

DAILY ACTIVITIES

Taking Medications 

Housework 

Using Phone 

Using Transportation 

Managing Money 

Shopping 

INDEPENDENT

 YES OR NO

Have there been any significant changes in the care recipient’s status (new diagnosis, safety risk, combative, 

cognitive or mental impairment, etc.)? Yes No

 If Yes, Please state change(s) _______________________________________ 

Recent diagnosis: ____________ Recent hospitalization: ____________ Surgeries: ___________ 

If there has been a change in address/phone for the care recipient, please state changes here: 

Is the care recipient receiving or applying for:

Medicaid (Title 19) 

CT Home Care Program for Elders (CCCI or SCAAA) Name of Case Manager:

Alzheimer’s Respite Care Program

____________ 

Comments/other information: 

 __

Connecticut Satisfaction Survey: East 7
__________________________________________________________________________________ 

__________________________________________________________________________________ 

Care Recipient INCOME 

 Joint 

Social Security (subtract Medicare premium), 

SSI, Railroad Retirement income 

 $___________ ____ 

 

Pensions, retirement income, annuities, 

Veteran’s benefits 

 $___________ ____

Interest and dividends $___________ ____

 

Other income (wages, net rental income, 

Non-taxable income) 

 $___________ ____

TOTAL INCOME $___________ 

If spouse has income separate from the applicant, please indicate approx. amount: $ ____________ 

Please update the financial information listed below. You may be asked to voluntarily cost share toward service 

granted based on the care recipient’s income. 

ASSETS 

Please include joint assets as well as those in care recipient’s name only. Joint 

Checking/savings accounts, IRAs, CDs,

Stocks/bonds 

 $___________ ____

 

 $___________ ____

 $___________ ____

TOTAL ASSETS $___________ 

If spouse has assets separate from the care recipient, please indicate approximate amount: $ _______ 

I certify that the information on this form is true, accurate, and complete. 

__________________________________________________________________________________ 

SIGNATURE OF CAREGIVER DATE 

Have there been any significant changes this past year for you, as the caregiver (change in medical condition: new 

diagnosis and/or increase in chronic condition, stress level, hospitalization, loss of support, loosing work directly 

related to caregiving, etc.)? Yes No 

 If Yes, Please state change(s) ______________________________________ 

Has there been a change in address/phone number for you, the caregiver, please state changes here: 

Emergency Contact if you, the caregiver, cannot be reached: 

Name_______________________ Phone_________________ Relation____________________ 

Connecticut Satisfaction Survey: East 8
National Family Caregiver Support Program Caregiver 

Quality Assurance Survey 2014 

We are always looking to improve the quality of our program and we cannot 

accomplish this without you. We would appreciate your response to the 

following survey. Please complete and return as soon as possible in the 

enclosed envelope. 

1. Overall, how satisfied are you with the respite service(s) and/or 

item(s) that you and/or your family member received? 

Would you say ...

 ___ Very satisfied 

Somewhat satisfied 

Somewhat dissatisfied 

Very dissatisfied 

 ___ 

 ___ 

 ___ 

Comments:

 

2. To what extent did the service(s)/item(s) that you and/or your family 

member received help you as a caregiver? 

Would you say...

 ___ They helped a lot 

They helped a little 

They did not help 

They made things worse 

 ___ 

 ___ 

___ 

Comments: 

3. Have the service(s)/item(s) enabled you to provide care for your 

family member for a longer time than would have been possible 

without these services? 

Would you say...

___ Yes, definitely 

Yes, I think so 

No, I do not think so 

No, definitely not 

___ 

___ 

___ 

Comments: 

Connecticut Satisfaction Survey: South Central 9
2014 SURVEY FOR CARE MANAGEMENT SERVICES 

1. Were you treated in a courteous and professional manner by the Care 

Manager? 

___ Yes ___ No ___ Not Sure 

2. Did you feel she understood the type of care you need to help you stay 

at home? 

___ Yes ___ No ___ Not Sure 

3. Was the Care Manager helpful in explaining the services available to 

meet your 

 care needs? 

 ___ Yes ___ No ___ Not Sure 

4. Was the Care Manager helpful in assisting you to arrange for services 

to meet your needs? 

___ Yes ___No ___Not Sure 

5. Were you satisfied with your participation in developing your care 

plan? 

___ Yes ___ No ___ Not Sure 

6. Do you have any suggestions to improve our care management 

service? 

___ Yes ___ No ___ Not Sure 

If yes, please explain:

_____________________________________________________________ 

____________________________________________________________ 

7. Would you use care management services if you needed them again? 

___ Yes ___ No ___ Not Sure 

Connecticut Satisfaction Survey: South Central 10
North Central Area Agency on Aging 

151 New Park Avenue, Box 75 

Hartford, CT 06106

 CONSUMER SATISFACTION QUESTIONNAIRE 2014-15

The North Central Area Agency on Aging seeks your feedback on the 

Connecticut National Family Caregiver Support Program. During this fiscal year, 

our records indicate that you received items and/or services from us. If you would 

please take a moment to complete this brief survey we would be most 

appreciative. 

If you would like this questionnaire to be sent in an alternative format, or would 

prefer to answer this questionnaire by telephone, please contact DamarisDeLeon at (860) 724-6443 x 289. 

1. Overall, how satisfied are you with the item(s) that you and/or your family 

member received? 

Not Satisfied Very Satisfied

1 2 3 4 5 

2. To what extent have the service(s)/item(s) that you and/or your family 

member received: 

Not very much A great deal

Reduced your stress

Saved you money 

Increased your family member’s safety

Improved your quality of life 

Improved your family member’s 

 1 2 3 4 5 

 1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

1 2 3 4 5 

Connecticut Satisfaction Survey: North Central 11
Quality of life 

Assisted your family member 

To stay at home 

 1 2 3 4 5

1 2 3 4 5 

 1 2 3 4 5 

4. How did you hear about program? Who referred you to the program? 

5. Can you think of ways in which our services could be improved to assist 

older adults and their families? 

6. Is there anything else you would like to tell us about our program? 

Optional Information: 

Your name: __________________________________________________ 

Mailing Address: ______________________________________________ 

Telephone: (H) _______________________________________________ 

Please return this survey to: 

 

NORTH CENTRAL AREA AGENCY ON AGING 

National Family Caregiver Support Program 

151 New Park Avenue, Box 75 

Hartford, CT 06106 

Attn: Damaris DeLeon 

Connecticut Satisfaction Survey: North Central 12
Attachment B-8 – HCBS Caregiver Services Consumer Survey 

June 2011 - FINAL 

Page 1 of 2 

Item 

#

HCBS Caregiver Services Survey Questions Answer Options 

As a result of the Caregiver Services, do you...

 Yes

 No

1. Have more time for personal activities? (For example: 

church, shopping for yourself, walking, reading, 

exercising, movies, talking with friends) 

Have more time to do daily activities or chores? (For 

example: house cleaning, yard work, shopping for 

groceries, running errands, picking up medications) 

Feel less stress? 

Have a clearer understanding of how to get the services 

you and your Care Receiver need? 

Know more about your Care Receiver’s condition or 

illness? 

Feel more confident in providing care to your Care 

Receiver? 

Have the Caregiver Services helped you to provide care 

for a longer period of time than would have been 

possible without these services? 

Would you say Caregiver Services have helped you be a 

better caregiver? 

Have the Caregiver Services helped your Care Receiver 

to continue to be able to live at home? 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

10. 

Overall, how satisfied are you with the Caregiver 

Services you receive? 

 Satisfied

Somewhat Satisfied 

Dissatisfied 





11. Who would you contact first if you had a problem with 

the Caregiver Services? 

 The Aide’s or Worker’s

Supervisor

Case Manager’s Supervisor

or Agency

Area Agency on Aging

Division of Aging Services

Do Not Know

Others: ________________











12. 

In your opinion, how could we improve Caregiver 

Services for you? Please mark all that apply.

 Need the same aides/workers

each time.

Need better trained

aides/workers.

I would like to choose my

aides/workers.

Need the aides/workers to do

more for me.

Need the aides/workers to

arrive on time as scheduled.









Georgia Caregiver Satisfaction Survey 13
Attachment B-8 – HCBS Caregiver Services Consumer Survey 

June 2011 - FINAL 

Page 2 of 2 

Item

#

HCBS Caregiver Services Survey Questions Answer Options

 Need the aides/workers for 

more hours and/or more 

days. 

Need the aides/workers to do 

things the way I want them 

to be done. 

Need aides/workers to stay 

the full amount of time 

scheduled. 

Need more information on 

my Care Receiver’s illness or

how to provide better care. 







13. Please tell us any other suggestions you have to improve

the quality of Personal Care Services you receive. 

Comments: 

Note: If the survey is to be administered by mail, please do not ask the consumer to identify him/herself, 

unless he or she wishes to be contacted for follow-up. Add lines at the end of the survey for the consumer to 

indicate voluntarily a desire for a contact and to provide his or her name and telephone contact information. 

Georgia Caregiver Satisfaction Survey 14
Kinship Care Participant Survey 

Background:

The Kinship Care Participant Survey tool is to be used twice annually (March and September) to 

gauge participants’ perceptions of the program and the program’s impact on Kinship families. If 

a participant leaves the program prior to the six month point, or prior to an annual review, the 

staff should attempt to use the survey as an exit interview. 

The primary goal of the survey is to determine the extent to which the program has made a 

positive difference in the consumers’ experience as grandparents or other relatives raising 

grandchildren or others in their care. A Likert scale is used to measure attitudes, preferences, and 

subjective reactions. Likert scales help get at the emotional and preferential responses people 

have to the program and services. Staff may administer the scale through an interview or 

provide the survey to program participants to self-rate their experience. Date the form at the 

space provided at the bottom. 

The Division has formulated survey questions that will capture data that address the major goals 

and desired outcomes of the program described in the guidelines, including questions adapted 

from the Family Empowerment Questionnaire. 

Data Analysis: 

Within fifteen (15) business days of the end of each survey period (March and October), each 

AAA should enter survey response data into AIMS. 

Using the Kinship Care Quarterly Narrative Report (Appendix 216-C), each AAA should 

describe the process by which the survey was conducted for that period, significant findings of 

the survey, and any actions planned as a result of the survey data, including how the information 

will be used to improve the program and to advocate for additional resources and services. If 

there are an unusually high proportion of non-respondents in a given area, address this in your 

analysis. 

 

Georgia Services and Satisfaction Survey 15
KINSHIP CARE SURVEY 

If you had any difficulty accessing any service, or were not satisfied with the service, please tell 

us about your experience: ________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

____________________________________________________________________________ 

Below is a list of services and resources. Please tell 

us whether you used any of these services or 

resources within the last 6 months and, if so, please 

indicate your level of satisfaction with the services 

you received. 

Did You

Use this 

Service?

If So, 

Were You 

Satisfied 

with the 

Service? 

Y N Y N 

Legal Assistance 

Financial Assistance 

Housing Resources 

Mental/Behavioral Health Services 

Food and Nutrition Services 

Child Care Services 

Physical Health Care Services/Medical Services 

School/Educational Resources 

Leisure/Recreational Resources 

As a result of participating in Kinship Care 

programs or services, please tell whether 

you agree or disagree with each of the 

following statements:

Strongly 

Agree

Agree Disagree Strongly 

Disagree

I feel that I am better able to cope with caring 

for the children I am raising than before I 

became involved in Kinship Care services 

and activities.

- - - -

I do not feel as stressed out as I used to. - - - -

I am enjoying life more now. - - - -

I think that I will be able to continue raising 

child(ren) in my care. - - - -

I plan to continue to participate in Kinship 

Care activities. - - - -

I feel as if my overall health and sense of 

well-being have improved. - - - -

I would recommend the Kinship Care 

program to others who are in the same 

situation as myself.

- - - -

Georgia Services and Satisfaction Survey 16
Below are a number of statements that 

describes how a grandparent raising a 

grandchild(ren) – or other relative 

caregiver - might feel about his or her 

situation. For each statement, please tell 

which response best describe how that 

statement applies to you:

Very 

True

Mostly 

True

Somewhat 

True

Mostly 

Not 

True

Not at 

all 

True

When problems arise with my grandchild, 

I handle them pretty well. - - - - -

I feel confident in my ability to help my 

grandchild grow and develop. - - - - -

I know what to do when there are problems 

with my grandchild. - - - - -

I am able to get information to help me better 

understand my grandchild. - - - - -

When I need help with other problems in my 

family, I am able to ask for help from others. - - - - -

When necessary, I will look for services for 

my grandchild and family. - - - - -

Are there any service or services that you need but have not been able to get? 

____ No ____ Yes - please describe what service or services: ________________ 

_____________________________________________________________________________ 

PLEASE PROVIDE THE FOLLOWING INFORMATION: 

Gender: ______ Male ______Female County of Residence: _________ 

Race: _______ American Indian/Alaskan Native

African-American

Native Hawaiian/Pacific Islander

______ Asian 

_______ ______White 

_______ ______Other 

Marital Status: ______Married ______Widowed ______Divorced/Separated 

______Domestic Partner ______Single 

Age: ____ 55 or younger ______ 56-64 ______65-74 _______ 75+ 

How many grandchildren are you caring for: ___1 ____ 2-3 ____ 4-5 ___ more than 5 

How long have you been caring for your grandchild or grandchildren: 

______less than 1 year _______ 1-2 years ________ 3-5 years _______more than 5 years 

Household Income per year: 

_____ less than $9,999 ____$10,000 - $19,999 ____$20,000 - $29,999 

_____$30,000 - $39,999 ____$40,000 - $49,999 ____ $50,000 or more 

_____ Prefer not to disclose 

Date Completed: _________________ 

Georgia Services and Satisfaction Survey 17
KDADS QI - OAA III E CAREGIVER CUSTOMER INTERVIEW PROTOCOL 

Page 1 of 4 

October 2013

Number 1 

Question How did you hear about the area agency on aging and the caregiver services? 

Measures (1) Family/friends

Newspaper

TV

Phone book

Community event

(2)

(3)

(4)

(5)

(6) Other:________________________________

(7) Unsure/Doesn’t want to answer

(9) Not applicable (doesn’t remember contact)

Policy Reference Data Collection

Number 2 

Question Have you had contact with the area agency on aging during the past 3 months?

Measures (1) Yes

f no, approximately when did you have contact?

(2) No 

(3) I

(7) Unsure/Doesn’t want to answer

(9) Not applicable (doesn’t remember contact)

Policy Reference(s) Data Collection

Number 3 

Question If/when you had contact with the AAA staff, were they friendly and helpful?

Measures (1) Yes

No

If no, explain

(2) 

(3) ______________________________________

(7) Unsure/Doesn’t want to answer

(9) Not applicable (doesn’t remember contact)

Policy Reference Data Collection

Number 4 

Question If you left a message for the AAA, did they return your call timely? (within a day or 

two?)

Measures (1) Yes

(2) No - Explain: ___________________________

(7) Unsure/Doesn’t want to answer

(9) Not applicable (no contact) 

Policy Reference Data Collection

Kansas Satisfaction Survey 18
KDADS QI - OAA III E CAREGIVER CUSTOMER INTERVIEW PROTOCOL 

Page 2 of 4 

October 2013

Number 5 

Question What caregiver information and/or services have you received from the AAA? 

Measures (1) Information about caring for a loved one

Information for yourself as the caregiver

Grandparents raising grandchildren assistance

(2)

(3)

(4) Other ______________________________

(7) Unsure/Doesn’t want to answer

(9) Not applicable (doesn’t recall contact with AAA)

Policy Reference Data Collection

Number 6

Question Do you feel the information/services provided were:

Measures (1) Very Helpful

Somewhat helpful

Not helpful

(2) 

(3) 

(7) Unsure/Doesn’t want to answer

(9) Not applicable (doesn’t recall getting services)

Policy Reference(s) Data Collection

Number 7 

Question Do you have any concerns about the information/services received?

Measures (1) Yes, Explain ________________________________

(2) No

(7) Unsure/Doesn’t want to answer

(9) Not applicable (doesn’t remember contact)

Policy Reference(s) Data Collection

Number 8 

Question Do you believe the information/services provided has helped you and the person

you provide care for remain independent at home? 

Measures (1) Yes

 Unsure/Doesn’t want to answer

Not applicable (doesn’t remember contact)

(2) No

(7)

(9) 

Policy Reference(s) Data Collection

Kansas Satisfaction Survey 19
KDADS QI - OAA III E CAREGIVER CUSTOMER INTERVIEW PROTOCOL 

Page 3 of 4 

October 2013

Number 9

Question Would you recommend these services to a friend or relative? 

Measures (1) Yes

(2) No

(7)Unsure/Doesn’t want to answer

(9) Not applicable (doesn’t remember contact)

Policy Reference(s) Data Collection

Number 10

Question If you had a complaint about the customer service you received from the AAA, 

how would you handle it or who would you contact? 

Measures (1) Staff supervisor

Head of agency

Discuss with person involved 

Not do anything

Not have contact with agency again

(2) 

(3)

(4) 

(5) 

(6) Other _______________________

(7) Unsure/Doesn’t want to answer

(9) Not applicable (doesn’t remember contact)

Policy Reference(s) Data Collection

Number 11

Question Do you feel safe at home?

Measures (1) Yes

(2) No, Explain___________________________

(7) Unsure/Doesn’t want to answer

Policy Reference(s) Data Collection

Number 12 

Question Do you have any suggestions for or comments about the Caregiver Program? 

Measures (1) Yes, Explain _______________________________________________

(2) No

(7) Unsure/Doesn’t want to answer

(9) Not applicable (doesn’t remember contact) 

Policy Reference(s) Data Collection

Kansas Satisfaction Survey 20
KDADS QI - OAA III E CAREGIVER CUSTOMER INTERVIEW PROTOCOL 

Page 4 of 4 

October 2013

Number 13

Question What item was purchased for you? 

Measures ASK ONLY OF THOSE ON THE FLEX SERVICE LIST

(1) List item_______________________________________

(7) Unsure/Doesn’t want to answer

(9) Not applicable (doesn’t recall item being purchased) 

Policy Reference(s) Data Collection

Number 14

Question How did this item help you? 

Measures ASK ONLY OF THOSE ON THE FLEX SERVICE LIST

(1) Remain independent in the home

Relief for caregiver

Assistance with grandchildren 

(2)

(3)

(4) Other, _____________________________

(7)Unsure/Doesn’t want to answer

(9)Not applicable 

Policy Reference Data Collection

Number 15

Question If this item had not been purchased for you thru the AAA, how would you have 

managed without it? 

Measures ASK ONLY OF THOSE ON THE FLEX SERVICE LIST

(1) Family would have purchased item. 

Would have done without.

(2) Church or other charitable organization would have purchased item.

(3) 

(7) Unsure/Doesn’t want to answer

Policy Reference(s) Data Collection

Number 16

Question If you had not been able to secure this item, how would it have affected your 

everyday life?

Measures ASK ONLY OF THOSE ON THE FLEX SERVICE LIST

(1) No impact

Decreased quality of life

Health impact

(2) 

(3) 

(4) Safety in the home

(5) Other __________________________________________

(7) Unsure/Doesn’t want to answer

Policy Reference(s) Data Collection

Kansas Satisfaction Survey 21
Family Caregiver Support Program Satisfaction Survey

 

 According to our records you have received the following services. 

 In person or phone consultation to discuss your caregiving situation 

Information and assistance to connect you with resources and services 

Assistance in receiving respite (a break from your caregiving) 

Assistance/subsidy toward adaptive equipment, assistive technology or other supplemental support 







 Support Group  Education/training  ( other) 

1. How long have you received caregiver support services from our agency?

 Less than 3 months  3-5 months  6-12 months  More than 1year

2. How helpful was meeting/consulting with (fill in name)? 

  Very helpful  Helpful  Somewhat helpful  Not helpful 

3. Did you find the caregiver action plan useful? 

  Yes  No  Not applicable/did not receive a plan 

4. Of the services that you received through the Family Caregiver Program which are more useful?

 In person consultation/meeting(s) 

Respite – a break from caregiving 

 Phone consultation 

Support group 

Other (write in) 

 Information/assistance/referral to resources 

 and services 

 Financial assistance/subsidy toward i.e. adaptive

 equipment, assistive technology 

 Caregiver education/training  

  

 5. As a result of the Family Caregiver Program services, do you: Yes No Unsure Not Applicable 

a) have a better understanding how to get needed services? 

b) know more about the condition or illness(es) of the care recipient?

c) feel more confident in providing care?

d) believe the services enabled you to provide care longer? 

e) feel better able to make decisions and solve problems related to

 your caregiving?

f) feel better able to cope with stress? 

g) take more time for your personal health and well-being?

6. How would you describe your overall experience with the

caregiver support services?

Excellent Good Fair Poor 

    

Date ___________ 

 

 Optional information: see over 

Thank you for completing this survey.

 Consumer #

 

 

Massachusetts Caregiver Satisfaction Survey 22
Comments: 

I would like someone to contact me regarding this survey.  Yes  No 

I would like additional assistance and/or information regarding the following: 

______________________________________________________________________________ 

______________________________________________________________________________ 

If you would like to be contacted, please complete below. 

Name ____________________________________ 

Telephone # _____________________________ 

Address __________________________________

 __________________________________

Email ____________________________________ 

 

 

 

Thank you

Massachusetts Caregiver Satisfaction Survey 23
MBA Caregiver Outcomes Survey Questionnaire 

Region: 

Year: 

Type: Frequency Counts for All Services 

Total number of caregivers surveyed (equals number of persons served) III-B and III-E 

Total number of completed caregiver survey returned 

Response rate % 

Caregiver Demographic Information

1. Gender 

Female 

Male 

2. Race/

White 

African American or Black 

Asian 

American Indian or Alaska Native 

Native Hawaiian or Other Pacific Islander 

Other 

3. Are you Hispanic or Latino? 

Yes 

No

4. Age Group 

Under 60 

60 - 74 

75 - 84 

85 or above 

5. Household Annual Income 

Less than Federal Poverty Guidelines for 2 person household

Less than Federal Poverty Guidelines for single person household

Frequency counts for Caregiver Services

(1) How long have you received caregiver services? 

Less than 3 months 

3 to 6 months 

6 to 12 months 

More than a year 

(2) Has a caregiver service helped you cope better? 

Not coping better 

Coping somewhat better 

Coping much better 

Minnesota Satisfaction Outcomes Survey 24
(3) Has a caregiver service improved your ability to provide care? 

Not more able to provide care 

Somewhat more able to provide care 

Much more able to provide care 

Do you believe that caregiver services will help you provide care longer?

Will not help me provide care longer 

Will help me provide care longer 

Will help me provide care much longer 

Are you (or care receiver) receiving any of the following? 

Respite 

Support group 

Counseling/Support Groups 

Education/Training 

Homemaker 

Home delivered meals 

Caregiver support at work 

Transportation 

Outside chore help 

Education about caregiving 

(4) 

(5) 

(6) Narrative/qualitative summary: 

Examples of Improvement:

Other Feedback:

Minnesota Satisfaction Outcomes Survey 25
ZIP CODE:

YOUR AGE: Age of Person in Care:

1. Are you caring for a:

Person 60 and older

Person with Alzheimer's or Dementia 

Related child 18 and under

Adult or Child with Disability

2. How did you first find out about the supportive services you received?

Comments:

3. How helpful was your contact with the Family Caregiver Support Program?

Very Helpful Somewhat Helpful Not Helpful

Comments:

4. Which of these services have you received? Mark all that apply

Information about services

Respite (A break from Caregiving)

Help in obtaining available services

Caregiver Training

Support Group

Other: (i.e. medical equipment)

If Other, please explain:

5. Overall, how would you rate the services you received?

Excellent Good Fair Poor

Comments:

6. If you received respite, how well did it meet your need? (Mark all that apply)

I received respite when I needed it

The amount of time given was adequate

I needed a longer break

I was comfortable with my respite care provider

Other: (Please explain)

CAREGIVER SUPPORT SATISFACTION SURVEY

Oregon Satisfaction Survey 26
7. Did the support services received by you or the person for whom you provide

 care, help you be a better caregiver?

YES NO

Comments:

8. Did the services you received help you keep your loved one at home?

YES NO

9. As a caregiver, I am experiencing the following: (Mark all that apply)

Feeling like I can't give care much longer

Not enough time for myself

Not enough time for my family

Interference with my work

Effects on my family relationships

Interference with my privacy

Conflicts with my social life

Strained relations with the person I care for

Depression

Stress

Anger

Physically fatigued

Feeling out of control

Isolation

Financial burdens

Other: (describe below)

10. As a caregiver the most important service I could receive is:

11. In my role as a caregiver, I find satisfaction in:

Contact Information: (optional)

Name:

Address

City State ZIP

Phone: ( ) Email

PLEASE RETURN IN THE ENCLOSED ENVELOPE

Thank you for your time completing this survey. The information you provide

will help us in making decisions regarding services for the 

Family Caregiver Support Program.

Oregon Satisfaction Survey 27
CAREGIVER RESPITE GRANT CONSUMER SURVEY 

Town of residence:__________________ County of residence:_____________ 

Please indicate your opinion on the following statements:

Type of respite grant received: 

Dementia Respite Grant 

Family Caregiver Respite Grant for Caregivers of Older Adults 

Family Caregiver Respite Grant for Older Relative Caregivers of Children

-

Strongly 

Agree

Agree Disagree Strongly 

Disagree

The respite grant gives me a break from 

my caregiving responsibilities. - - - -

The services I obtain with the respite grant 

help me maintain my physical health. - - - -

The services I obtain with the respite grant 

help me maintain my emotional wellbeing. - - - -

The respite grant helped me take care of 

myself - - - -

The services I obtain with the respite grant 

improve my ability to care for my family 

member.

- - - -

The respite grant helps me continue 

caregiving so my family member can live 

in the place of his/her choice. - - - -

The respite grant provided me with the 

flexibility to choose helpful ways to attain 

respite. - - - -

The respite grant helped me to use 

supports such as Powerful Tools for 

Caregivers, Memory Café, Alzheimer’s 

Association supports, and others

- - - -

Vermont Dementia Respite Caregiver Survey 28
Please use the space on the back of this survey for any comments you would like to make or 

if you wish to be contacted about a specific problem or concern about the respite 

grant.→→→

Thank you for taking the time to complete this survey. Please return this survey in the preaddressed, pre-stamped envelope that you received with the survey by May 31, 2014. 

Comments: 

________________________________________________________________

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________

________________________________________________________________ 

________________________________________________________________ 

________________________________________________________________ 

OPTIONAL 

Please note: Your responses to this survey are anonymous and confidential. However, if you 

would like help with a problem or concern, you may sign below and let us know how to reach 

you. Please indicate who you would like to have contact you: 

_____Department of Disabilities, Aging & Independent Living, 

 Division of Disability and Aging Services staff 

_____Area Agency on Aging staff 

Your name: (print) ____________________________

Address: ___________________________

 ___________________________ 

Phone number: 

Email: 

Best time to contact: 

 ___________________________

___________________________

______________________

Vermont Dementia Respite Caregiver Survey 29