Your Area Agency on Aging needs your input on this survey in order to determine your needs as a caregiver and the best way to meet those needs. The information you share is critical and will remain confidential. Additionally, the more feedback we receive from you the better we will be able to work together toward developing programs and services.

1. I am caring for: Spouse Mother Father Mother-in-law Father-in-law Other (If other, enter here)

2. Do you live with the person(s) for whom you are caring?Yes No

3. When you began caring for your loved one, how many hours per week did you think it would take to provide care?

4. On average, how many hours per week do you actually provide care?

5. Employment Status: Full-Time Part-Time

6. Do you have other caregiving responsibilities (children, grandchildren, other minors)?No Yes Specify relationship:

7. What do you hope to accomplish as a caregiver?

8. What types of care do you provide for your loved one? Check all that apply.

Personal Care Transportation Safety/Supervision Shopping Housekeeping Financial Management Medication Monitoring Meal Preparation Financial Management Other (Please list)

9. Generally, how overwhelmed do you feel about your caregiving responsibilities? Check the number that most applies: (1 being not at all, 5 being very)

1 2 3 4 5

10. Who usually assists you when you need help with your caregiving Responsibilities? (Please check all that apply)

Relative Service Provider Friend Support Group Social Worker Church Neighbor Do Not Require Assistance No Available Help Other (Please describe)

11. What is the biggest problem or barrier for you as a caregiver? Language Barrier, I donŐt know where to find help, Care recipient refusing outside help, etc.)

Language Barrier Not Enough Time Work Schedule Financial Restraints Other (Please describe)

12. What services would make your job as caregiver less overwhelming or more manageable?

Support Groups Caregiver Education Classes Sitter/Companions Meal Preparation Skilled Nursing Care Personal Care Transportation Medication Monitoring Safety/Supervision Shopping Legal/Benefits Information Money Management Resource Information Other (Please describe)

13. Which programs or agencies are the most help to the person for whom you are caring?

Caregiver Information:

Male Female

Race: White Black/African American Hispanic/Latino Asian American Indian Hawaiian/Pacific Islander Two or more Other (Please describe)

Care Recipient #1 Information:

Male Female

Race: White Black/African American Hispanic/Latino Asian American Indian Hawaiian/Pacific Islander Two or more Other (Please describe)

Care Recipient #2 Information:

Male Female White Black/African American Hispanic/Latino Asian American Indian Hawaiian/Pacific Islander Two or more Other (Please describe)

14. ADDITIONAL COMMENTS: Any information you want to add that would help us to better assist you in your caregiving.

If you would like more information about the Caregiver Initiative Program call Patricia Bordie (512) 916-6060. Our toll-free number is 1-800-622-9111. You can also visit our website and access our agency email at www.aaacap.org. If you would like us to send more information and program updates please fill out the contact information below. Thank you.

Your Name: Address:

City, State, ZIP:

Area Code: Telephone Number:

Email

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