SUA Resource Library: 

Grandparent Assessment 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; 

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

contexts; and 

3. 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. 

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 

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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
Grandparent Assessment Materials 

New Hampshire Grandparent / Relative Caregiver Assessment .................................................................. 3

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Grandparent/Relative Caregiver Assessment Instrument 2013 Page 1 of 5 

Grandparent/ Relative Caregiver Assessment 

DATE ____________________ 

Section 1: Initial Intake Questionnaire for the Grandparent/ Relative Caregiver 

Name of Grandmother/Relative Caregiver: ______________________________ 

Name of Grandfather/Relative Caregiver: ______________________________ 

Address: _________________________________________________________________________ 

Mailing address (if different from the address above): 

___________________________________________________________________________________ 

___________________________________________________________________________________ 

Daytime phone:_______________ Alt phone:______________ Email:_____________________ 

What is the best method to contact you? Daytime phone Alt phone Email 

Name of Child (Children) Date of Birth: Your relationship* to the child: 

living in your home that you are raising:

________________________________ ______________ _________________________________ 

. ________________________________ ______________ _________________________________ 

________________________________ ______________ _________________________________ 

________________________________ ______________ _________________________________ 

________________________________ ______________ _________________________________ 

________________________________ ______________ _________________________________ 

(*Relationship such as grandmother, aunt, etc.) 

GRANDPARENT/ RELATIVE CAREGIVER INFORMATION 

(related to whomever is the primary caregiver of the child/children) 

Gender: Male Female Date of Birth:___________________________(required) 

Marital status: Single Married Divorced Widowed Domestic partner 

New Hampshire Grandparent / Relative Caregiver Assessment 3
Grandparent/Relative Caregiver Assessment Instrument 2013 Page 2 of 5 

Read this statement to the caregiver: You may choose to not answer the next 2 questions. This 

information will not be used to determine eligibility, nor will it affect the services you receive. 

Ethnic origin: Hispanic or Latino Yes No 

Race: African American or Black American Indian or Alaskan Native 

 Asian Native Hawaiian or Other Pacific Islander 

 White (Alone) non-Hispanic White (Alone) Hispanic 

 A person reporting 2 or more races Other 

Length of time you have been raising the child/children: _______________ (In years and months) 

Primary language spoken at home: ___________ Do you need an interpreter? Yes No

Are there other members in your household other than yourself, spouse/partner and the children? 

Name Relationship

___________________________________________________________________________________

___________________________________________________________________________________ 

Do you have any other caregiving responsibilities? (i.e. other adults, other family members) 

______________ ________________________________________________________

Section II: In Home Evaluation 

Financial 

Is the primary grandparent/relative caregiver currently employed? Yes No Has this changed 

in the past year? Yes No

Note to interviewer: If the grandparent/relative is working they can get assistance with childcare – must have 

legal guardianship or custody. They need to apply for this at the District Office where they live. 

Comments: ________________________________________________________________________ 

Are there medications; supplies or treatments that either you and/or the children should have, but cannot 

afford to buy? Yes No _____________________________________________________ 

Do you anticipate any significant expenses in caring for the child or children this coming 

year?_______________________________________________________________________________

_______________________________________________________________________

New Hampshire Grandparent / Relative Caregiver Assessment 4
Grandparent/Relative Caregiver Assessment Instrument 2013 Page 3 of 5 

Household Income: 

Read statement to caregiver: Providing the information below is optional and is not required to determine 

eligibility. Only your responses without your personal identifying information will be shared. The U.S. 

Administration on Aging requires the collection of this information to gain a better understanding of the 

situations and needs of family caregivers nationwide. 

How much TOTAL income did you and your family receive this past year, not just from wages or 

salaries but from ALL sources -- that is, before taxes and other deductions were made? Was it ... 

(READ CATEGORIES, and check the appropriate range) 

ANNUAL INCOME 

 Less than $20,000 $ 20,001 - $40,000 

 $40,001 - $60,000 $–Over $60,000 

 Refused Doesn’t Know 

 Not Applicable 

Grandparent/Relative Caregiving Experiences 

What are some of the difficulties you are experiencing in raising your grandchild/ren/relative child? 

___________________________________________________________________________________ 

___________________________________________________________________________________ 

___________________________________________________________________________________ 

What is the most rewarding thing for you about raising the child/children? __________________

 ______________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________ 

How are other family members involved in helping you with the child/children? __________________ 

___________________________________________________________________________________ 

___________________________________________________________________________________

 Does your living or housing arrangements cause any difficulties?

Yes No Explain: ________________________________________________________ 

___________________________________________________________________________________ 

__________________________________________________________________________________ 

Does the fact that you live in a (rural, small town, suburban, urban) area create any problems for you 

with regard to your caring role? Yes No Explain:

__________________________________________________________________________________ 

 

 Do you attend a support group? Yes No If no, why not? If yes, is it helpful? _____________ 

___________________________________________________________________________________ 

___________________________________________________________________________________

Interviewer thoughts/observations: ____________ 

 

New Hampshire Grandparent / Relative Caregiver Assessment 5
Grandparent/Relative Caregiver Assessment Instrument 2013 Page 4 of 5 

Supports and Services 

Is anyone available to provide respite (relief) when you are unable to provide care? Yes No

If yes, is such assistance available on short notice? Yes No

Explain who is available: 

Have you received respite or supplemental services through ServiceLink and the NH Family Caregiver 

Support Program in the past? Yes No If yes, how were you helped? 

___________________________________________________________________________________ 

Who else helps out? Please list other informal (non-paid) supports below (alternate phrasing: Who else 

in your family or community is interested in the well-being of the child/children?)

Name Relationship to Caregiver Where do they live? Help they provide 

____________________________________________________________________________________________________ 

____________________________________________________________________________________________________ 

____________________________________________________________________________________________________ 

Do you need in-home care or assistance for yourself (such as homemaker services, support for 

emergencies, help in organizing services or training support)? 

 _________________________ ______ 

 Do you need Respite Care (services to take care of the child or children in order for you to take some 

time for yourself either in the home, out of the home, or overnight)? 

 

 

Is DCYF involved? yes no ______________________________________________________ 

___________________________________________________________________________________ 

[Note to interviewer: If DCYF is involved they are they are probably getting support. If not, two 

possible choices: (1) Request a child-only TANF grant, or (2) Work with DCYF to become a licensed 

foster parent] 

Are you receiving TANF (Temporary Assistance for Needy Families) for the child/children? It is also 

commonly called the ‘Child Only Grant or Relative Payee Grant’ and is based on the child’s income.

 yes no _____________________________________________________________________ 

___________________________________________________________________________________ 

New Hampshire Grandparent / Relative Caregiver Assessment 6
Grandparent/Relative Caregiver Assessment Instrument 2013 Page 5 of 5 

Are you receiving “shelter allowance” along with the TANF grant? This helps with the additional costs 

of housing, utilities and expenses in adding children to their household. yes no ___________ 

___________________________________________________________________________________ 

[Note to interviewer: They can apply at the District Office where they live. They will need to fill out an 

application and show proof of relationship] 

Have you applied for Healthy Kids? yes no (if no, they can apply at the District Office)______ 

____________________________________________________________________________________ 

Do you need other services (such as assistance with meals, transportation, equipment/home 

modifications, medications, legal assistance, counseling or support groups)? 

 ____________________________________ 

 ______________________________________________________ 

 

What additional resources do you think you would benefit from? Comments 

 

 

Would you like information any topics? Yes No 

Explain: 

 

 

Have you looked at other sources for help? Yes No 

Explain: ____________ _____________________________________________ 

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 

Notes/Observations: 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

New Hampshire Grandparent / Relative Caregiver Assessment 7