About You 1 Your Centrelink Reference Number (CRN) 2 Your Date of Birth / / 3 Where you live Please tick one In a metropolitan area (i.e. within 30 kms of a capital city) In a regional area In a remote area 4 Your gender Male Female 5 Is English the main language you use at home? No Yes 6 Are you an Aboriginal or Torres Strait Islander person? No Yes Is your ability to participate in leisure, community, study, or employment activities limited due to any of the following? No Yes Calls more than once a week for you to help with the person’s care at day activity, work placement or other regular programs You have to stay while the person attends a weekly activity due to their care needs The person you care for is unable to attend programs or organised activities due to their care needs Restriction on the hours the person can attend programs (e.g. day activity, post-school options or supported employment) due to the severity of their condition Having to attend appointments with the person more than once a fortnight Providing emergency care and support to the person Sleep disruption for you on most nights due to the person’s care needs or behaviours because of their disability or medical condition About the person who is receiving care Centrelink Reference Number (CRN) of the person who is receiving care (if known) Do you consent to us contacting you about this field test? 11 Date of birth of the person who is receiving care Go to next question Please provide your phone number below / / 12 Gender of the person who is receiving care Male Would you like information on other carer support services? Female 13 What is your relationship to the person receiving care (e.g. parent, child, grandparent, friend)? Go to next question Please use my phone number provided above OR I provide this care in this person’s home (i.e. in a private home that is the residence of the carer or the person receiving care) No Yes time
Learning, planning and problem solving If the person you provide care for has a condition that changes from day to day or week to week, please indicate the level of help you provide on most days or weeks. If someone other than you (e.g. NDIS, home care or other service provider) helps with learning, planning and problem solving, do not include this care. Please tick one box in each row that best describes the help you provide to this person because of their disability or medical condition. Level of help I provide With these activities No help I do not have to help at all or not relevant to my circumstances Some help I have to give some prompts, reminders or supervision A lot of help I have to give a lot of physical help or continual prompts and guidance Complete help I have to give total help or do this task completely for this person Learning new skills and knowledge e.g. learning how to do things, how things work, understanding ideas and concepts Remembering things that are important for daily living e.g. how to do routine activities such as cook a meal, how to get to and from familiar places such as home to shops and back Concentrating and persisting at tasks e.g. being able to pay attention long enough to complete basic tasks and activities Planning and organising daily or weekly activities e.g. preparing a weekly shopping list, following a cooking recipe, planning outings, managing appointments Solving problems e.g. managing day to day problems such as what to do when an appliance breaks down; making routine day to day decisions such as what to wear, handling money