Your Name (required)

Are you an unpaid caregiver? YesNo

As a caregiver, what do you need?

What is your age? 18-2525-3535-4545-5555-6565+

Are you FemaleMale

Who are you caring for? Spouse/PartnerParentChildIn-LawOther Family MemberFriendNeighborOther

Please explain "Other" here:

Does that person have a disability, an illness, special needs, or frail elderly?  (Please explain)

What is the age of the person you are caring for?

Do you live with the person you are caring for? YesNo

If not, how far do you live from the person you are caring for (in miles)?

Do you assist with activities of daily living? YesNo

Do you work outside the home while caregiving? YesNo

Does caregiving affect your work or social life? YesNo

Do you have to rearrange your work schedule, decrease your hours, or take unpaid leave because of your caregiving responsibilities?YesNo

How many hours a day do you spend on caregiving?

How many hours per week?

How many years have you been caregiving for this person?

Do you feel isolated as a caregiver? YesNo

Do you feel depressed as a caregiver? YesNo

What is your biggest challenge or obstacle in caregiving?

How do you, as a caregiver, view your own health? ExcellentGoodFairPoor

Do you feel that a cost-free respite service for caregivers would have value in your community?YesNo

Would you contact a cost-free respite service for caregivers if your community had this available to you?YesNo

Would you have confidence in a cost-free respite service that trained volunteers to provide in-home care relief?YesNo

Would it be helpful and beneficial to have contact with other caregivers for support and assistance? YesNo

Would it be helpful and beneficial to have a cost-free caregivers educational series available in your community?YesNo

Would you attend a cost-free caregivers educational series?YesNo

What city/county do you reside in?