SHIP Dementia Caregiver Survey

SHIP Dementia Caregiver Survey

Thank you for taking our survey! The information you provide will help the Florida Department of Elder Affairs and their partners better understand the needs of caregivers. We ask that you complete the questions.

This survey is intended for dementia caregivers. Please share this with any caregivers you may know.

Your responses will not affect any services or benefits you receive because we will not know who answered this questionnaire. You are not required to complete this survey and you do not need to answer any question you don’t want to answer. Your individual responses are confidential. Responses will only be reported after they are combined with the responses from everyone who took the survey.

Please read each question carefully. Some questions may be skipped depending on how you answered the previous question.

Thank you for your cooperation and input.

Demographics

Please provide the following information for both yourself and the person you care for. Please leave blank any information you do not wish to answer.

What is your zip code?

What county do you live in?

Select

Todays date

Do you have regular access to the Internet?

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Your Gender

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Your Age Group

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Your Race

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Person you care for Gender

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Person you care for Age Group

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Person you care for Race

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Please read the following statement and answer the question below:

Some people provide regular unpaid care or assistance to a family member or friend who has a health condition, long-term illness or disability. They provide this care so that their family member or friend can maintain an independent lifestyle. This family member or friend could be an adult or a child. Assistance can range from a few hours of shopping and cleaning to intensive medical or personal care. Tasks can include shopping, house cleaning, cooking, giving medications, toileting assistance and so forth.

During the past month, did you provide this kind of unpaid care or assistance to a family member or friend?

Select or enter value

Do you consider yourself to be a caregiver for your family member or friend?

Select

If yes, how long have you been a caregiver?

Select

Support and Services

Do you feel empowered to be a caregiver?

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Have you received any education on how to be a caregiver on the following topics?

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Would you be interested in receiving education on caregiving?

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Are you familiar with the Alzheimer’s Association 24/7 helpline or the FL Elder Helpline? If yes, which one?

Have you called either of these? If so which one?

Do you participate in a support group?

Select

If so, which kind of support group?

Select

If other please explain

If not, why not?

Select

If other please explain

Do you need financial support for caring for your loved one with dementia?

Select

If yes, do you know how to access financial support through your Area Agency on Aging?

Select

Does your loved one live at home or in a facility?

Select

If your loved one lives at home? Do they utilize home health or adult day care services?

Select or enter value

Have you checked to ensure your home is safe?

Select

Do you have preparations in place if your loved one wanders?

Select

If not, is it because you do not have access to wandering services or information?

If not, what services and support do you need?

Select

Other

If other please list

Respite Care

Please read the definition of respite care, below, and answer the questions that follow.

Respite care is temporary or short-term care of an individual that is provided by someone other than the person’s normal caregiver. It is designed to give the caregiver brief personal time away from the daily tasks of caregiving. Respite care is provided either in-home or out-of-home. It is offered by community organizations such as mental health centers, nursing homes, churches, or private agencies. These organizations provide either a paid worker or a trained volunteer to provide respite care.

Before you read the definition above, did you know what respite care was?

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Have you used respite care in the past?

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What do you think are the biggest benefits of getting respite care services?

If you have never received respite care services, please think about what the benefits would be if you did receive respite care.

Please choose three things that would be most beneficial to you:

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In your opinion, how true is each statement below?

If you have never used respite care services and don’t know an answer, or if you don’t have an opinion, please mark the last column “I don’t know.”

Respite care provides safe and secure care

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Respite care reduces my stress level as a caregiver.

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Respite care increases my ability to effectively provide care for my family member or friend.

Select

Respite care reduces the risk of neglect or mistreatment of my family member or friend.

Select

Respite care allows my family member or friend to live at home rather than moving to a residential facility, which could help reduce costs of care.

Select

I don't trust respite care providers.

Select

I am uncomfortable with having strangers in my home.

Select

My family member or friend would not allow someone else to assist him or her.

Select

Emergency Respite

Emergency Respite means the placement of an in-home respite care worker during an unplanned or planned event, or the temporary placement of the recipient outside the home, to substitute for the caregiver.

Have you ever used emergency respite care?

Select

Do you know any organizations in your area that offer emergency respite care?

Select

Is there any information or advice you wish you had that would help you access emergency respite care?

What types of respite care do you think are available in your area?

Select

If you have received information about respite care services in the past, where did you get the information?

Mark all that apply.

Select

Has anyone ever helped you in the process of getting respite care services, such as provide you contact information for service providers and help you schedule the services?

Select

If chose yes, who helped you?

Select or enter value

Do you know how to find a respite provider that is licensed and reputable?

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Do you know how to find out if a potential respite provider is a good fit for your needs?

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Have you ever been unable to get respite care when you looked for it?

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If you have looked for respite care and NOT been able to get it, why were you not able to get it? (Choose the top 3 reasons.)

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In a typical 6-month time period, about how often do you feel you need respite care?

Even if you have never used respite care, please think about how often you could use it.

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How often have you actually received respite care in the past 6 months?

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When you use respite care, is it easy or difficult to arrange?

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If it is sometimes difficult to arrange respite care services, why is it difficult?

If you were to receive respite care services when you need it, how would it affect the amount of stress you feel about your caregiving responsibilities?

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Is there any information or advice you wish you had that would help you access respite services?

How many people do you provide unpaid care or assistance for?

Select

If you provide care or assistance for more than one person, please think about the person for whom you provide the most care and answer the following questions for that person.

What kinds of care do you provide for your family member or friend?

Mark all that apply.

Select

How much time do you spend each week helping this friend or family member?

Select

If you used respite care in the past, who provided the service?

Mark all that apply.

Select

Where was the respite care provided?

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If you provide care or assistance for more than one person, please think about the person for whom you provide the most care and answer the following questions for that person.

What is your relationship to the person for whom you provide care?

I am the person's:

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What is the primary condition of the person you care for?

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Caregiver Health

Do you believe you are taking care of your physical health?

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What resources would help you take better care of your health?

Do you feel your mental health is suffering?

Select

Have you been diagnosed with depression or another mental health condition?

Select or enter value

Diagnosis and Care Planning

Did your loved one get a proper diagnosis?

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Did you feel their doctor properly prepared you?

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Did the doctor sit down and create a care plan with you?

Select

Do you have a care plan in place for your loved one?

Select

Do you have advance directives in effect?

Select

Do you know about clinical trials in your area?

Select

Are you completing this survey on behalf of someone else?

Select

If yes

please let us know who you are in relation to the caregiver for example: I am the caregivers daughter.

Additional comments

please provide any additional feedback that would be helpful here

Thank You!

Thank you for your help! Your responses will help us better understand the needs of caregivers and the ways they access respite care services.

Send me a copy of my responses

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