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Model Eldercare Survey

INSTRUCTIONS: THANK YOU FOR PARTICIPATING IN OUR SURVEY. REGARDLESS OF WHETHER YOU HAVE ELDERCARE RESPONSIBILITIES, PLEASE COMPLETE SECTION I: DEMOGRAPHICS. ALL ANSWERS ARE CONFIDENTIAL! PLEASE DO NOT WRITE YOUR NAME ON THIS SURVEY!

 

Section I: Demographics

1. What is the zip code of your home address? ___________

2. What is your age group?

____ Under 30 years  _____ 46-50 years
____  30-35 years _____  51-55 years
____  36-40 years _____  56-60 years
____  41-45 years  _____  61 or older


3. Gender _____ female _____ male

4. Do you work _____ full-time or _____ part-time?

5. What is your occupation? ____________________________

6. Do you have children under age 18 living in your household?

____ yes ____ no

7. Aside from children, who else lives with you? (Check all that apply.)

____  spouse  ____  brother or sister
____  father ____ aunt or uncle
____  mother  ____  another relation
 ____  father-in-law  ____  a friend
____  mother-in-law  ____  other


8. Do you provide some degree of care for anyone age 50 or older?

____ yes ____no

9. If no, do you anticipate caring for an older relative within the next five years?

____ yes ____ no

10. Please check the statement that best reflects your attitude:

____ I favor employer-sponsored eldercare benefits and/or services for employees.

____ I do not favor employer-sponsored eldercare benefits and/or ser vices for employees.

____ No comment.

____ Other______________________________

11. What is your annual family income?

____  Under $15,000  ____  $35,001 - $45,000
____  $15,001 - $25,000  ____  $45,001 - $55,000
____  $25,001 - $35,000  ____  Over $55,000


IF YOU ANSWERED "NO" TO QUESTION 8 ABOVE, YOU HAVE COMPLETED THE QUESTIONNAIRE. PLEASE RETURN THE QUESTIONNAIRE TO _____________________________. IF YOU HAVE ELDERCARE RESPONSIBILITIES, PLEASE CONTINUE WITH SECTION II OF THE SURVEY.

 

Section II: Adult Care

Adult care involves responsibility for an older parent or other relative, whether that person lives with you or not.

12. If you answered "yes" to question 8, are you the primary caregiver or are there others who provide most of the care?

____ primary ____ others

13. Is the other caregiver someone who lives in your household?

____ yes ____ no

14. Where does the person for whom you have caregiving responsibilities live?

____ With me.

____ In his/her home nearby.

____ In his/her home out-of-town.

____ In a nursing home nearby.

____ In a nursing home out-of-town.

Other (specify) _______________________

15. If this person lives with you, who provides care while you are at work?

 Most Often  Sometimes
Cares for self  ____  ____
Adult family member  ____  ____
Family member under 18  ____  ____
Paid caregiver  ____  ____
Adult day care center  ____  ____


16. Please check all the caregiving tasks that you have undertaken in the last 3 months. (Check all that apply.)

____ Provided direct financial support.

____ Managed person's finances.

____ Performed household chores for person such as shopping, cooking, laundry, maintenance of living quarters.

____ Assisted person with personal care (dressing, bathing, feeding, toileting, etc.).

____ Provided help moving about in the house or apartment.

____ Provided transportation.

____ Administered medications.

____ Provided companionship by personal visits or by telephone.

____ Made or received telephone calls for person.

____ Arranged/coordinated outside help for person.

____ Arranged medical or service appointments.

____ Filled out health care or legal forms.

____ Other (specify)_______________________.

17. How long have you been caring for this individual?

_________________

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

____ Less than 5 hours per week.

____ 5-15 hours.

____ 16-25 hours.

____ More than 26 hours per week.

19. What kinds of problems do you encounter in providing this help?

 

  No
Prob.		 Few
Prob.		 Some
Prob.		 Many
Prob.		 Severe
Prob.
Finding needed services          
Physical and/or emotional strain          
Cost of care          
Finding time          
Providing transportation          
Keeping my work schedule          


20. How much, on average, do you spend per month to provide care? _______________________

21. In the last 3 months, how many days have your caregiving responsibilities caused you to:

 

  none 1-3 days 4-6 days 7-9 days 10+ days
Miss work?          
Be late to work?          
Leave early?          
Receive or make
phone calls at work		          


22. When you need to be away from work for a short time to take the person you care for to a doctor's appointment or for an emergency, how does your supervisor manage your absence?

____ Allowed to use personal leave time.

____ Allowed to use sick leave.

____ Allowed to make up the lost time.

____ A demerit or mark goes against my work record.

____ Other: ___________________________________

23. How does your supervisor respond to your family responsibilities that may occur during work time?

____ Supportive.

____ Reluctant, but allows necessary absence.

____ Critical.

____ Other:________________________________.

24. Which of the following employer-provided benefits do you take advantage of or would like your employer to provide?

 

  Use Would like to have
Flextime    
Compressed work week    
Job sharing    
Permanent part-time    
Use of sick leave for family members    
Leave of absence    
Referral service    
Seminars on caregive topics    
Support groups    
Caregiver fair    
Employee assistance program    
Dependent care assistance program    
Financial assistance    


25. Any additional comments? ____________________________________

____________________________________________________________

____________________________________________________________

PLEASE RETURN TO ______________________ OR DROP IN BOX

LOCATED AT ______________________________, THANK YOU.

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