Survey for Individuals Caring for an Older Adult

Support Services and Programs for Family Caregivers

A. Respite Care

1. Are any of the following services offered in your area? (Mark all that apply.):

2. Which of the following services have you been able to access in your area? (Mark all that apply.):

3. Has there ever been circumstances that prevented you from using any type of respite care?:

Yes

No

4. If yes, how might we make these more accessible to you in the future (e.g. better location or schedule, less cost)?:

B. Individual Learning and Skill-Building Programs

6. Do you know of any local organizations that teach these skills for family caregivers? (Mark all that apply.):

How to Make Home a Safer Place

Understanding More About My Loved One's Condition

Appropriate Exercises I can do at Home

Planning, Cooking & Serving More Nutritious, Cost Efficient Meals

Communicating & Reasoning Skills for Those with Memory Loss or Cognitive Decline

How to Help Loved Ones with Their Emotions, Relaxation, Calming Techniques, etc.

Using App-based Services like Ride Sharing (Uber/Lyft) or Grocery Delivery

Building Awareness and Understanding of Elder Abuse and/or Financial Exploitation

I am Unaware of any Learning or Skill Building in my Area

7. Which types of learning or skill building sessions for caregivers have you attended?:

9. Has there ever been an circumstances that have prevented you from attending any of the learning or skill building sessions?:

Yes

No

10. If yes, how might we make these more accessible to you in the future (e.g. better location or schedule, less cost)?:

C. Social and Individual Creative and Therapeutic Activities and Opportunities

If Other::

13. How frequently have you attended these types of activities?:

14. Has there ever been circumstances where you have not been able to attend any of the social and creative activities?:

Yes

No

15. If yes, how might we make these more accessible to you in the future (e.g. better location or schedule, less cost)?:

Demographics

2. How long have you been caring for your loved one, or, did you care for your loved one?:

Less Than a Year

1 - 3 Years

3 - 5 Years

5+ Years

4. Are/Were you working outside the home while providing care?:

No

Yes, Full-Time

Yes, Part-Time

7. Does the person for whom you provide care live with you?:

Yes

No

8. Certain conditions make providing care more challenging; if you feel comfortable, please let us know if your loved one faces any of the following:

Memory challenges

Mobility challenges

Elder Abuse and/or Financial Exploitation

9. Certain conditions make providing care more challenging; if you feel comfortable, please let us know if you face any of the following:

Memory challenges

Mobility challenges

Elder Abuse and/or Financial Exploitation

10. Your zip code:

11. Your loved one's zip code:

13. Do you live in Central or Western New York?:

Central

Western