POMP 8 Comprehensive Caregiver Survey Draft[1]

8/14/2019 POMP 8 Comprehensive Caregiver Survey Draft[1]

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INTRODUCTION

Hello. May I speak to [CAREGIVERS NAME]? My name is [INTERVIEWERSNAME] from [AGENCYS NAME]. We are conducting a survey to find out how we canhelp meet the needs of caregivers and seniors being served by [AGENCYS NAME].Our records show that you have received caregiver support services* [USE LOCALNAME AS NEEDED] from [AGENCYS NAME] to help you take care of an elderlyperson.

* Please provide a brief description of your local Family Caregiver Support

Program [USE LOCAL NAME AS NEEDED] or other service received.

May we ask you a few questions about your caregiving experiences while caring for[CARE RECEIVERS NAME]?IF NO, THANK THE PERSON AND TERMINATE PRESENT INTERVIEW;

OTHERWISE CONTINUE WITH SURVEY INTRODUCTION BELOW.

This survey typically takes about 20 minutes. Is this a good time for us to talk?

[IF YES, GO TO NEXT PAGE]

[IF NO] What is another time that would be better for you?(Get time and phone number where they can be reached.)Day: ________________ Time: ___________ Date: __________Should we reach you at a different phone number?Telephone number? __________________________

[CONFIRM TIME AND PHONE NUMBER WHERE THEY CAN BEREACHED. TERMINATE PRESENT INTERVIEW.]

1

COMPREHENSIVE SURVEY ON CAREGIVER SATISFACTIONAND OUTCOMES

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Office Use only: Client ID:____________________________________ Date:______________________Time begun: _______________ Time ended: _______________ Total time: _____________ minutes


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1. Are you still caring for [CARE RECEIVERS NAME] or [Someone 60 years ofage or older]?

Yes ............... 1 GO TOQUESTION 2

No ...... 2 CONTINUEWITH QUESTION 1A BELOW

1A. IF NO, ASK THE FOLLOWING QUESTION:

Could you tell me what happened to change your caregiving situation? [Do not read list.Check all that apply.]

A. Care receiver died 1B. Care receiver was placed in a nursing home 1C. Care receiver was placed in an assisted living facility 1D. Care receiver was placed in a family type group home (family care home) 1E. Care receiver is getting help temporarily from a different caregiver,

but I will resume caregiving later 1F. Care receiver has a different caregiving arrangement permanently 1G. Care receiver got better and no longer needs help 1H. Care receivers needs exceed CAREGIVERS capacity to help 1I. CAREGIVERS health status has declined 1J. CAREGIVERS employment status has changed 1K. CAREGIVERS family situation has changed 1L. Other reason: Please specify:____________________________________ 1

If possible, encourage the caregiver to continue with the survey. Explain that if the

caregivers situation has changed, he/she should answer the questions recalling his/her

recent experience as a caregiver. If the person is not willing to continue the survey,

thank him/her and terminate the interview.

2. Has someone at [AGENCYS NAME] helped you or given you information toconnect you to the services and resources that you need as a caregiver?

Yes ..................................................................................... 1

No .......................................................................................... 2

DONT KNOW...................................................................... -8

3. Have you received Respite Care, which allows you a brief break while temporarycare is provided to [CARE RECEIVERS NAME], either in your home orsomeplace else?

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Yes,..........................................................................

.......................................................................

...................................................................... 1No ...........................................................................

.......................................................................

....................................................................... 2DONT KNOW.......................................................

.......................................................................

......................................................................-8

4. Have you received caregiver training or education, including participation insupport groups, to help you make decisions and solve problems in your role as acaregiver?

Yes.............................................................................................................................................. 1

No ...........................................................................

.......................................................................

....................................................................... 2DONT KNOW.......................................................

.......................................................................

......................................................................-8

5. Has the [INSERT LOCAL PROGRAM NAME]provided you with anySupplemental Services to help you provide care, such as [INSERT ADESCRIPTION OF LOCAL SERVICES, e.g.HDM, Transportation, PersonalEmergency Response System, etc.]?

Yes.............................................................................................................................................. 1

No ...........................................................................

.......................................................................

....................................................................... 2

DONT KNOW....................................................................................................................................................................................................-8

6. Of the caregiver services you received, which one service was the most helpful?(DONT READ LIST. READ ONLY WHEN THE RESPONDENT NEEDS

REMINDER. CHECK ONLY ONE.)

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Help or Information connecting youto services and resources,..................................

.......................................................................

........................................................................ 1Respite Care Services,............................................

.......................................................................

........................................................................ 2Caregiver Training or Education,

including Counseling or a Support Group, or...

.......................................................................

........................................................................ 3Other Supplemental Support Services or

Assistance? (SPECIFY_______________).....

.......................................................................

........................................................................ 4DONT KNOW.......................................................

.......................................................................

.......................................................................-8

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7. Does [CARE RECEIVER'S NAME] receive the following service?

Yes No DONT KNOW

A.) Adult day care (center-provided daycare)? 1 2 -8

B.) Case Management [care monitoring, carecoordination, service linkages, oradd localservice definition]?

1 2 -8

C.) Home Care Service (includes Personal Care,Homemaker and Chore Services)?

1 2 -8

D.) Home Delivered Meals? 1 2 -8

E.) Transportation Service (includes Assisted

Transportation)? 1 2 -8

F.) Information about services? 1 2 -8

G.) Other services or assistance (not listed above)?SPECIFY:__________________________________

1 2 -8

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8. As a result of the caregiver and care receiver services, do youYes No DONT KNOW

A.) Have more time for personal activities? 1 2 -8

B.) Feel less stress? 1 2 -8

C.) Have a clearer understanding of how to get theservices you and {CARE RECEIVER} need?

1 2 -8

D.) Know more about {CARE RECEIVERS}condition or illness?

1 2 -8

E.) Feel more confident in providing care to[CARE RECEIVERS NAME]?

1 2 -8

F.) Believe that the services enable you to providecare longer?

1 2 -8

G.) Think that the caregivers services you receivebenefit the [CARE RECEIVER] too?

1 2 -8

H.) Receive other benefits (e.g. State HealthInsurance Program, Home Energy AssistanceProgram)?

SPECIFY: ______________________

1 2 -8

9A. Would [CARE RECEIVERS NAME] have been able to continue to live in thesame home if caregiver and/or care receiver services had not been provided?

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Yes.................................................................................................................... 1 [GO TO Q. 10]

No ..........................................................................

.......................................................................

............................................ 2 [GO TO Q. 9B]DONT KNOW.......................................................

.......................................................................

.............................................-8 [GO TO Q. 10]

9B. Where would [CARE RECEIVERS NAME] be living?[DONT READ LIST. CHECK ONLY ONE ANSWER.]

In your [caregivers] home, ....................................

...........................................................

............................................................ 1In the home of another family member or friend, ..

...........................................................

............................................................ 2In an assisted living facility, or ..............................

...........................................................

............................................................ 3In a nursing home?..................................................

...........................................................

............................................................ 4CARE RECEIVER WOULD HAVE DIED...........

....................................................................................................................... 5OTHER(SPECIFY: ______________________).

...........................................................

............................................................ 6

10. Thinking about the services that [CARE RECEIVERS NAME] has received andthe caregiver services that you have received, how would you rate these services?[READ LIST. CHECK ONLY ONE.]

Excellent,............................................................................................................................................................................................................... 1

Very good,...............................................................

.......................................................................

........................................................................ 2Good,.......................................................................

.......................................................................

........................................................................ 3

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Fair, or.....................................................................

.......................................................................

........................................................................ 4Poor?.......................................................................

.......................................................................

........................................................................ 5DONT KNOW.......................................................

.......................................................................

.......................................................................-8

11. Would you recommend these services to a friend?

Yes............................................................................................................................................... 1

Not Sure................................................................................................................................................................................................................. 2

No ...........................................................................

.......................................................................

........................................................................ 3

12. How have these services affected you and your caregiving tasks? [WRITERESPONSE VERBATIM.]______________________________________________

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13. From your perspective, how could these services be improved? [DONT READ LIST. YOU MAY CHECK MORE THAN ONE ANSWER]

Services would be improved if they were:

A. Less Complicated (less bureaucracy/paper work) 1B. More Timely (start sooner/provided when needed) 1C. More Competent (better skills, professional demeanor) 1D. More Reliable (come as scheduled) 1E. More Consistent (same worker each time) 1F. More Personable (friendly, respectful) 1G. Sufficient (need more of current service) 1H. No Suggestion 1I. Other: 1

Please specify _______________________________________

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In this section of the survey, we would like to obtain some basic information about howmuch care you provide to [CARE RECEIVERS NAME].

CGI 1.How long have you been caring for [CARE RECEIVERS NAME]?

|__|__| Months |__|__| Years

REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

CGI 2.Thinking about all the family members or friends who provide help, care, orsupervision for [CARE RECEIVERS NAME], what proportion of the care doyou provide during a typical week? [READ LIST. CHECK ONLY ONE.]Would you say

Nearly all,................................................................

.......................................................................

........................................................................ 1About half,..............................................................

.......................................................................

........................................................................ 2A little? ...................................................................

.......................................................................

........................................................................ 3REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

CGI 3A........In your judgment can [CARE RECEIVERS

NAME] be left alone (meaninghe/she does not require 24 hour help/supervision)? Would you say

Yes, [CARE RECEIVER] can be left alone forextended periods with no concerns...................

.......................................................................

.............................................. 1 Go to Q CGI 4.Yes, [CARE RECEIVER] can be left alone but

needs to be checked on in person several times

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a day..................................................................

.......................................................................

.............................................. 2 Go to Q CGI 4.Yes, [CARE RECEIVER] can be left alone, but

only for short periods of time (an hour or less)

.......................................................................

.............................................. 3 Go to Q CGI 4No, [CARE RECEIVER] cannot be left alone and

needs 24-hour supervision................................

.......................................................................

............................................ 4 Go to Q CGI 3B

...........................................................................REFUSED...............................................................

.......................................................................

.............................................-7 Go to Q CGI 4.

...........................................................................DONT KNOW.......................................................

.......................................................................

.............................................-8 Go to Q CGI 4.

...........................................................................

CGI3 B. Are you responsible for providing help orsupervision to [CARE RECEIVERS NAME] ona 24-hour basis?

Yes,..........................................................................

.......................................................................

....................................................................... 1No ,..........................................................................

.......................................................................

....................................................................... 2REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

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CGI 4. [NOTE: IF THE ANSWER IS "YES," TO ANY ITEM IN THE LIST, MARKAS "YES".] Does [CARE RECEIVERS NAME] require help with the followingactivities because of his/her impairments?

A.) Dressing, eating, bathing, or getting to thebathroom?

Yes.............................................................................................................................................. 1

No ............................................................

.......................................................................

..................................................... 2 (Skip to C)REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

[IF "YES"]

B.)Who is primarily responsible for helping withthese activities?

Me (Caregiver being interviewed)..........................

.......................................................................

....................................................................... 1Unpaid help (friend or family)................................

.......................................................................

....................................................................... 2Paid help (nurse or home aide).......................

.......................................................................

........................................................................ 3REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

..............................................................................................................................................-8

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C.) Taking medicine or changing bandages?

Yes.............................................................................................................................................. 1

No ............................................................

.......................................................................

..................................................... 2 (Skip to E)REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

[IF "YES" ]

D.)Who is primarily responsible for helping withthese activities?


.......................................................................


.......................................................................


.......................................................................

........................................................................ 3REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

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E.) Keeping track of bills, checks, or otherfinancial matters?

Yes.............................................................................................................................................. 1

No ............................................................

.......................................................................

..................................................... 2 (Skip to G)REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

[IF "YES"]

F.)Who is primarily responsible for helping withthese activities?


.......................................................................


.......................................................................


.......................................................................

........................................................................ 3REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

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G.) Preparing meals, doing laundry, or cleaningthe house?

Yes.............................................................................................................................................. 1

No ............................................................

.......................................................................

...................................................... 2 (Skip to I)REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

[IF "YES"]

H.)Who is primarily responsible for helping withthese activities?


.......................................................................


.......................................................................

....................................................................... 2

Paid help (nurse or home aide)...................................................................................................................................................................... 3

REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

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I.) Going shopping or to the doctors office?

Yes.............................................................................................................................................. 1

No ............................................................

.......................................................................

..................................................... 2 (Skip to K)REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

[IF "YES"]

J.)Who is primarily responsible for helping withthese activities?


.......................................................................


.......................................................................


.......................................................................

........................................................................ 3REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

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K.) Arranging for care or services provided byothers?

Yes.............................................................................................................................................. 1

No ............................................................

.......................................................................

.................................................... 2 (Skip to M)REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

[IF "YES"]

L.)Who is primarily responsible for helping withthese activities?


.......................................................................


.......................................................................

....................................................................... 2

Paid help (nurse or home aide)...................................................................................................................................................................... 3

REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

M. [IF ALL RESPONSES ARE NO, REFUSED, OR DONT KNOW, ASK:]

What kind of care do you provide for [CARE RECEIVERS NAME]?

[WRITE RESPONSE VERBATIM. IF NO CARE PROVIDED, WRITE

NONE.]

_________________________________________________________________________________

_________________________________________________________________________________

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The next group of questions ask about the rewards and burdens you may feel as a

caregiver.

CGRB 1. I would like to ask you about positive aspects ofcaregiving and give you some choices for answers. Pleasechoose the answer that best tells how you feel:

Alway

s/Usuall

y

S

ome-time

s

Rarely/Never

DON

TKNOW

DOESNOT

APPLY

A.) As a caregiver, how often do you feel thatyou are helping [CARE RECEIVERS NAME]remain at home and not assisted livingfacility?

1 2 3 -8 -1

B.) How often does being a caregiver for [CARERECEIVERS NAME] give you the joy ofspending time with someone you care

1 2 3 -8 -1

C.) How often does being a caregiver provideyou with a sense of accomplishment? 1 2 3 -8 -1

D.) How often does providing care for [CARERECEIVERS NAME] give you the satisfactionof knowing that they are receiving the

1 2 3 -8 -1

E.) How often do you feel that [CARE RECEIVERSNAME a reciates the care that ou are

1 2 3 -8 -1

F.) As a caregiver, how often do you feel youare fulfilling your duty by caring for [CARE

1 2 3 -8 -1

G.) OTHER (SPECIFY:____________________) 1 2 3 -8 -1

CGRB 2. In your experience as a caregiver, what is the one most positiveaspect of caregiving? [READ LIST. CHECK ONLY ONE.]

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Helping your care receiver live at home,......

............................................................

............................................................. 1Spending time with someone you care

about,......................................................

............................................................

............................................................. 2Feeling a sense of accomplishment,.............

............................................................

............................................................. 3Satisfaction that care and attention are

received,.................................................

............................................................

............................................................. 4Being appreciated, or...................................

............................................................

............................................................. 5

Fulfilling a duty?....................................................................................................... ............................................................. 6

OTHER (SPECIFY:______________________)..

............................................................

............................................................. 7NONE............................................................

.............................................................

............................................................. 8REFUSED......................................................

.............................................................

.............................................................-7DONT KNOW................................................

.............................................................

.............................................................-8

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CGRB 3 Now I would like to ask youabout potential difficulties you mayface in caring for [care recipient].

Please respond to each of thefollowing questions with one of theoptions provided.

In your experience as a caregiver,how often do you feel that

Always/

Usually

Some

-time

s

Rarely/

Never

DONT

KNOW

DOESNOT

APPLY

A.) Caregiving creates a financial 1 2 3 -8 -1

B.) Caregiving does not leave youenough time for yourself?

1 2 3 -8 -1

C.) Caregiving does not leave

enough time for your family?

1 2 3 -8 -1

D.) Caregiving interferes with your 1 2 3 -8 -1

E.) Caregiving negatively affectsyour health? 1 2 3 -8 -1

F.) Caregiving conflicts with yoursocial life? 1 2 3 -8 -1

G.) Caregiving causes you stress? 1 2 3 -8 -1

H.) OTHER (SPECIFY:____________________________

1 2 3 -8 -1

CGRB 4. What is the greatest difficulty you have faced in yourcaregiving? [READ LIST. CHECK ONLY ONE.] Would you say caregiving:

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Creates a financial burden,..........................

.............................................................

............................................................. 1Doesnt leave enough time for yourself,......

.............................................................

............................................................. 2Doesnt leave enough time for your family,.

.............................................................

............................................................. 3Interferes with your work,............................

.............................................................

............................................................. 4Creates or aggravates health problems, .....

.............................................................

............................................................. 5Conflicts with your social life........................

.............................................................

............................................................. 6Creates stress?.............................................

.............................................................

............................................................. 7OTHER (SPECIFY:__________________).......

.............................................................

............................................................. 8REFUSED......................................................

.............................................................

.............................................................-7DONT KNOW................................................

.............................................................

.............................................................-8

CGRB 5. Has providing care for [CARE RECEIVERS NAME] ever interferedwith your employment ?

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Yes.............................................................

.............................................................

.............................. 1 (Go to Q CGRB 5A)No ................................................................

.............................................................

............................ 2 (Skip to Q. CGRB 6)NOT APPLICABLE..........................................

.............................................................

............................-1 (Skip to Q. CGRB 6)REFUSED......................................................

.............................................................

.............................-7 (Skip to Q. CGRB 6)DONT KNOW................................................

.............................................................

.............................-8 (Skip to Q. CGRB 6)

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CGRB5A. Because of providing care for [CARE RECEIVERS NAME], have you. . . [READ LIST AND CHECK ALL THAT APPLY.]

YES NO

A. Quit work or retired early ....................................... 1 2

B. Taken a less demanding job. .................................. 1 2C. Changed from full time to part-time work. ............ 1 2

D. Reduced your official working hours. ..................... 1 2

E. Lost some of your employment fringe benefits...... 1 2

F. Had time conflicts between working and caregiving. 1

..........................................................................2

G. Used your vacation time to provide care. .............. 1 2

H. Taken a leave of absence to provide care. ............. 1 2

I. Lost a promotion .................................................... 1 2J. Worked less than your normal number of hours last month

because of providing care for [CARE RECEIVERS NAME] .. 1 2

K. Other [SPECIFY: ______________________]................ 1 2

CGRB 6. Do you have any kind of health problem, physical condition, ordisability that affects the kind or amount of care that you can provide to[CARE RECEIVERS NAME]?

Yes 1 (Go to CGRB 6A)

No 2 (Skip to D1)

REFUSED -7 (Skip to D1)

DONT KNOW -8 (Skip to D1)

CGRB 6A. What is that problem, condition or disability? (Do not readresponses. Code all that apply and probe: Is there anything else?)

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1. Back problems and other joint problems/ Arthritis. 1

.............................................................................2. Heart problems/High Blood Pressure

/Hypertension /Stroke .............................

.............................................................

..............................................................13. Diabetes..................................................

.............................................................

..............................................................1

.............................................................4. Allergies/Asthma/Other breathing/lung

problems.................................................

.............................................................

..............................................................1

.............................................................5. Mental health (anxiety, fear, depression,

emotional problems). .............................

.............................................................

..............................................................1

.............................................................6. Eye problems..........................................

.............................................................

..............................................................1

.............................................................7. Other(SPECIFY:

______________________ )...........................

.............................................................

..............................................................1

.............................................................REFUSED......................................................

.............................................................

........................................-7 (Skip to D1)DONT KNOW................................................

.............................................................

........................................-8 (Skip to D1)

CGRB 6B. Have your caregiving activities created or worsened anyof these conditions, problems or disabilities?

YES 1

NO . 2NOT APPLICABLE.. -1REFUSED . -7DONT KNOW .. -8

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We are interested in knowing more about the demographic characteristics of our

clients. We would appreciate it if you would answer a few questions about you. All

of this information will be kept confidential.

D1. What is your gender?[RECORD SEX OF RESPONDENT. DONT ASK IF OBVIOUS]MALE.....................................................................

.......................................................................

........................................................................ 1FEMALE.................................................................

.......................................................................

........................................................................ 2

D2. In what year were you born?

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YEAR............................................................................................................................ |__|__|__|__|

REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

D3. What is your highest education level?Less than high school Diploma...............................

.......................................................................

....................................................................... 1High school Diploma..............................................

.......................................................................

....................................................................... 2Some college, including Associate degree..............

.......................................................................

....................................................................... 3Bachelors Degree...................................................

.......................................................................

....................................................................... 4Some post-graduate work or advanced degree.. .

............................................................. ....................................................................... 5

REFUSED...............................................................

..............................................................................................................................................-7DONT KNOW.......................................................

.......................................................................

......................................................................-8

D4. Are you Spanish, Hispanic or Latino?

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YES.........................................................................

.......................................................................

........................................................................ 1NO...........................................................................

.......................................................................

........................................................................ 2REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

D5. What is your race? Check all that apply.A. American Indian or Alaskan Native..................

.......................................................................

.........................................................................1

B. Asian................................................................... ..............................................................................1

C. Black or African-American...............................

.......................................................................

.........................................................................1

........................................................................D. White/Caucasian .............................................

.......................................................................

.........................................................................1

........................................................................E. Native Hawaiian/Other Pacific Islander...........

.......................................................................

.........................................................................1

........................................................................F. Other Race (SPECIFY _________________).

.......................................................................

.........................................................................1

........................................................................G. REFUSED.........................................................

.......................................................................

.......................................................................-7H. DONT KNOW.................................................

.......................................................................

.......................................................................-8

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D6. What is your marital status? Now married...........................................................

.......................................................................

....................................................................... 1Widowed.................................................................

.......................................................................

....................................................................... 2Divorced..................................................................

.......................................................................

....................................................................... 3Separated.................................................................

.......................................................................

........................................................................ 4Never Married.............................................

.....................................................................

....................................................................... 5REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

....................................................................... 6

D7. Where is your home located? Would you say

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In a City,..................................................................

.......................................................................

........................................................................ 1In a Suburban Area, or............................................

.......................................................................

........................................................................ 2In a Rural area?.......................................................

.......................................................................

........................................................................ 3DONT KNOW.......................................................

.......................................................................

.......................................................................-8

D8. Wed like to ask about who lives in your household. Do youYes No

A. Live alone? 1 2

B. Live with your spouse? 1 2

C. Live with your children? 1 2

D. Live with other relatives? 1 2

E. Live with domestic partner? 1 2

F. Live with non-relatives other thandomestic partner?

1 2

D9. How many people live in your household, including yourself?

NUMBER OF HOUSEHOLD MEMBERS.......................................................................... |__|__|

DONT KNOW......................................................

.......................................................................

.......................................................................-8

D10. Which category best describes your total gross household annual income for thelast 12 months? Would you say

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$5,000 or less..........................................................

.......................................................................

........................................................................ 1$5,001 - $10,000.................................

.......................................................................

........................................................................ 2$10,001 - $20,000...................................................

.......................................................................

........................................................................ 3$20,001 - $30,000,..................................................

.......................................................................

........................................................................ 4$30,001 - $40,000,..................................................

.......................................................................

........................................................................ 5

$40,001 - $50,000, ................................................................................................................................................................................................ 6

$50,001 - $75,000, or...........................................................................

...........................................................................7

Over $75,000?...........................................................................

...........................................................................8REFUSED

...........................................................................

...........................................................................-7

DONT KNOW...........................................................................

...........................................................................

-8

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D11. What is [CARE RECEIVERS NAMES] relationship to you?

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CARE RECEIVERS NAME is your

Husband ...........................................................

.................................................................

...................................................................1Wife...................................................................

.................................................................

...................................................................2Domestic partner...............................................

.................................................................

...................................................................3Father (including step father)............................

.................................................................

...................................................................4Mother (including step mother)........................

.................................................................

...................................................................5Grandfather (including step grandfather) ........

.................................................................

...................................................................6Grandmother (including step grandmother)......

.................................................................

...................................................................7Brother (including step brother)........................

.................................................................

...................................................................8

Sister (including step sister)..................................................................................................................................................................9

Uncle (including step uncle).............................

.................................................................

.................................................................10Aunt (including step aunt)................................

.................................................................

.................................................................11Son (including step son) ...................................

.................................................................

.................................................................12Son-in-Law (including step son-in-law)...........

.................................................................

.................................................................13Daughter (including step daughter)..................

.................................................................

.................................................................14

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Daughter-in-Law (incl. stepdaughter-in-law) ..

.................................................................

.................................................................15Other relative (not mentioned above]...............

.................................................................

.................................................................16Friend or Neighbor or Another Person..............

.................................................................

.................................................................17DONT KNOW.................................................

.................................................................

................................................................-8

D12. Does [CARE RECEIVERS NAME] live with you?YES.........................................................................

.......................................................................

.........................................................................1

.................................................. [GO TO D14]NO...........................................................................

.......................................................................

...............................................2 [GO TO D13]REFUSED...............................................................

.......................................................................

...............................................-7 [GO TO D13]

D13. Does [CARE RECEIVERS NAME] live alone?

Yes ......................................................................................................................................................................................................................... 1

No ..........................................................................

.......................................................................

....................................................................... 2DONT KNOW.......................................................

.......................................................................

......................................................................-8

D14. What is the gender of [CARE RECEIVERS NAME]? [DON'T ASK IF

OBVIOUS, JUST CHECK.]

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Male .......................................................................

.......................................................................

........................................................................ 1Female ....................................................................

.......................................................................

........................................................................ 2

D15. What is the age of [CARE RECEIVERS NAME]?NUMBER OF YEARS...........................................

.......................................................... |__|__|__|REFUSED...............................................................

.......................................................................

.......................................................................-7DONT KNOW.......................................................

.......................................................................

.......................................................................-8

CLOSE: Thank you very much for your time and cooperation. Your responses have

been very helpful to us.

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OPTIONAL

The next two questions ask you to think about what additional services and

information may be helpful to you as a caregiver.

O 1. In addition to the kinds and amounts of services you are receiving, {and theservices that [CARE RECEIVERS NAME] is receiving}, what additional ornew kinds ofhelp would be valuable to you as a caregiver?[READ LIST. CHECK YES OR NO FOR EACH ONE.]

Yes No

A.) Housekeeping assistance for [CARERECEIVERS NAME],

1 2

B.) Shopping assistance for [CARE RECEIVERSNAME],

1 2

C.) Transportation assistance for [CARERECEIVERS NAME],

1 2

D.) Assistance in making meals for [CARERECEIVERS NAME],

1 2

E.) Assistance in bathing, dressing, grooming,toileting, feeding, and other personal care for[CARE RECEIVERS NAME],

1 2

F.) Adult daycare for [CARE RECEIVERSNAME],

1 2

G.) Assistance in getting other family membersinvolved in caring for [CARE RECEIVERSNAME],

1 2

H.) Assistance in administering and monitoringside effects of medicine for [CARE RECEIVERSNAME] etc,

1 2

I.) In-home respite care 1 2

J.) Help with money management and financialadvice,

1 2

K.) Other services or assistance (not listedabove)? SPECIFY: _____________________, or

1 2

L.) No additional help needed? 1 2

M.) DONT KNOW -8

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O 2. What additional or new kinds ofinformation would be valuable to you as acaregiver? [READ LIST. CHECK YES OR NO FOR EACH ONE.]How about

Yes No

A.) A help line/ central place to call to find outwhat kind of help is available and where to get it,

1 2

B.) Someone to talk to/counseling services orsupport groups,

1 2

C.) Information about how to care for [CARERECEIVERS NAME]s condition or disability,

1 2

D.) Information about changes in laws that might

affect your situation,

1

2

E.) Information about how to select a nursinghome, group home, assisted living facility or othercare facility,

1 2

F.) Information on how to pay for nursing homes,assisted living facilities, adult day care and otherservices,

1 2

G.) Information on how to deal with agencies(bureaucracies) to get services,

1 2

H.) Information on health insurance and/or longterm care insurance,

1 2

I.) Other information not listed above?

1. SPECIFY: ______________________, OR 1 2

J.) No additional information needed? 1 2

K.) DONT KNOW -8

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OPTIONAL

Would you like us to send you information on services we have for caregivers?

YES.........................................................................

.......................................................................

.........................................................................1

.......................................... [GO TO NEXT Q]NO...........................................................................

.......................................................................

.........................................................................2

...................................... [END INTERVIEW]REFUSED...............................................................

.......................................................................

..................................-7 [END INTERVIEW]DONT KNOW.......................................................

.......................................................................

..................................-8 [END INTERVIEW]

What types of information would you like to obtain?Please list the resources you have locally and have the caregiver choose from the list.

[ ] ________________________

[ ] ________________________

[ ] ________________________

[ ] ________________________

[IF YES: GET NAME AND ADDRESS FOR SENDING INFORMATION.]

ADDRESS: Can I have your name and address, please?

______________________ ___________________________First Name Last Name

______________________________________________________Mailing Address

_______________________ ______________ ____________

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City State Zip Code

INTERVIEWER NOTE: GET INFORMATION ON CAREGIVERS REQUIRINGASSISTANCE. TEAR OUT THE OPTIONAL PAGES OF THE

QUESTIONNAIRE AND PASS THE NAME(S) ON TO YOUR SUPERVISOR OR

STAFF WHO CAN PROVIDE THE DESIRED INFORMATION OR

ASSISTANCE.


Version: 7-9-08

POMP 8 Comprehensive Caregiver Survey Draft[1]

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Transcript of POMP 8 Comprehensive Caregiver Survey Draft[1]