Form 7 Title VI Tribal Caregiver Survey
Annual Performance Reporting of the Administration for Community Living’s American Indian, Alaskan Natives and Native Hawaiian Programs
Title VI Tribal Caregiver Survey
Evaluation of Older Americans Act Title VI Programs-Tribal Caregivers Survey
OMB: 0985-0059
Form Approved
OMB No.: XXXX-XXXX
Expiration Date: XX/XX/2017
This
section asks about your background, and the person you provide care
for.
Have you received any caregiver support services within the last 12 months from [INSERT NAME OF PROGRAM]? For example, these may include [INSERT SHORT LIST OF THE TYPES OF SERVICES OFFERED].
1 Yes PLEASE CONTINUE
2 No Thank you for your time, but the focus of this survey is on people who have received caregiver support services within the last 12 months.
How long have you been receiving caregiver support services?
1 Less than 6 months
2 Between 6 months and 1 year
3 More than 1 year
In your role as a caregiver, how many people do you care for?
1 1
2 2
3 3
4 4 or more
3a. If you care for a child/children under 18, how many children do you care for?
1 1
2 2
3 3
4 4 or more
For
the following questions, think about the person with whom you spend
the most time as a caregiver.
What is your relationship to the person you care for?
The person I care for is my:
1 Spouse or partner
2 Parent
3 Grandparent
4 Brother or sister
5 Aunt or uncle
6 Adult son or daughter/Son-in-law or daughter-in-law
7 Child under 18 years old such as a grandchild, great niece or great nephew
9 Other relative not mentioned above (please describe): ____________
10 Someone else not mentioned above (please describe): ___________
How old is the person you care for? __________
Where does the person you care for live?
1 Lives alone
2 Lives with a spouse or partner who is not me
3 Lives with me
4 Lives with a family member other than me
5 Other (please describe): ______________________
Please take a moment to think about all of the care that the person you care for needs. Are you the sole provider of care for that person?
1 Yes, I am the sole caregiver
2 No, other people help provide care
7a. If you checked “No”, how many other people help provide care to that person?
1 One other person helps provide care
2 Two other people help provide care
3 Three or more people help provide care
How many hours in an average week do you spend providing care for this person?
Hours: ___________
Do you currently have a job for which you receive pay?
1 Yes, I work full time for wages
2 Yes, I work part time for wages
3 No, I am retired
4 No, I do not currently work a job for wages
The
questions in this section ask about the caregiver support you may
have received in the last 12 months from [INSERT
PROGRAM NAME].
In the last 12 months, has someone from the program given you information to connect you to any services and/or resources, including services or supports for the person you care for?
1 Yes
2 No
10a. If YES, how easy to understand was the information?
1 Very easy to understand
2 Somewhat easy to understand
3 Not very easy to understand
4 Not at all easy to understand
As a result of getting this information were you able to connect to the services or resources you needed?
1 Yes, I got all of the services and/or resources I needed
2 Yes, I got some of the services/resources I needed
3 No, I did not get any of the services and/or resources I needed
In the last 12 months, have you received a break while someone takes your place as the caregiver? This service is sometimes called “respite care.”
1 Yes
2 No
12a. If YES, which type(s) of respite care do you usually receive in a given month? (CHECK ALL THAT APPLY)
1 In-home respite, where someone comes to the home to take care of the person you care for
2 Daytime care for an adult or a grandchild, where the person you care for goes to a program during the day
3 Overnight respite care in a facility outside the home (e.g., nursing home, childcare facility, etc.)
4 Overnight respite care in the home
5 Other (please describe): _____________________________
How many hours of respite care do you usually receive in a month?
Hours:__________ 1 I do not receive this service
Overall, how would you rate the respite care you received in the last 12 months?
1 Very Good
3 Good
4 Poor
5 Very Poor
6 I did not receive this service in the last 12 months
Is the number of hours of respite care you receive each month enough?
1 Yes, it is enough but more would be better
2 Yes, it is enough
3 No, it is not enough
4 I do not receive this service
How many hours of respite care would you like to have in a month?
Hours: _________
In the last 12 months, have you received any caregiver training or education, including counseling or support groups, to help you make decisions or solve problems in your role as caregiver?
1 Yes
2 No
17a. If YES, which type(s) of service did you receive? (CHECK ALL THAT APPLY)
1 Caregiver education or training, such as classroom or Internet courses
2 Individual counseling to assist with your specific caregiver situation
3 Caregiver support groups
4 Other (please describe): ___________________________
17b. If YES, did any of the training, education, counseling or support group services talk about dementia or Alzheimer’s?
1 Yes
2 No
Overall, how would you rate the caregiver training, education, counseling, or support group services you received in the last 12 months?
1 Very Good
2 Good
3 Poor
4 Very Poor
5 I did not receive this service in the last 12 months
The
next questions ask about other
services —these do not
include help connecting to services/resources, or respite care, or
education/training, or counseling/support groups—that you as
the caregiver, or the person you care for, have received in the last
12 months.
In the last 12 months, has the program provided you with any supplemental services to help you provide care? Supplemental services may include transportation; nutritional supplements, such as Boost or Ensure; devices, such as potty seats, canes or walkers; a personal emergency response system; stipends; etc.?
1 Yes
2 No
19a. If YES, which supplemental services did you receive? (CHECK ALL THAT APPLY)
1 Devices (e.g., canes, walkers, potty seats)
2 Case management (i.e., coordination and care management)
3 Congregate meals (e.g., meals at a center)
4 Home-delivered meals
5 Home health aide (not respite)
5 Chore assistance (e.g., light housekeeping, laundry, chopping wood)
6 Home modification or adaptive equipment (e.g., grab bars, ramps, bath chair)
7 Incontinence supplies (e.g., Depends, Poise)
8 Legal assistance
9 Medical devices (e.g., nebulizer, hospital bed, wheelchair)
10 Nutritional supplements (e.g., Ensure, Boost)
11 Personal emergency response system
12 Emotional or mental health services for the person you care for
13 Transportation
14 Emergency supplies for children
15 Stipends
16 Other (please describe): _______________________
19b. If YOU DID NOT receive any supplemental services in the last 12 months, which supplemental services do you think would be helpful to receive?
(CHECK ALL THAT APPLY)
1 Devices (e.g., canes, walkers, potty seats)
2 Case management (i.e., coordination and care management)
3 Congregate meals (e.g., meals at a center)
4 Home-delivered meals
5 Home health aide (not respite)
5 Chore assistance (e.g., light housekeeping, laundry, chopping wood)
6 Home modification or adaptive equipment (e.g., grab bars, ramps, bath chair)
7 Incontinence supplies (e.g., Depends, Poise)
8 Legal assistance
9 Medical devices (e.g., nebulizer, hospital bed, wheelchair)
10 Nutritional supplements (e.g., Ensure, Boost)
11 Personal emergency response system
12 Emotional or mental health services for the person you care for
13 Transportation
14 Emergency supplies for children
15 Stipends
16 Other (please describe): _______________________
Overall, how would you rate the supplemental services you received in the last 12 months?
1 Very Good
2 Good
3 Poor
4 Very Poor
5 I did not receive this service in the last 12 months
In the last 12 months, have you received a voucher, cash, or individual budget from the program that allows you to purchase goods or services for the person(s) you care for? By “voucher or budget payment,” we mean that you were given an allowance where you can decide by yourself what to buy or whom to hire.
1 Yes
2 No
21a. If YES, how did you use the voucher, cash, or individual budget?
(CHECK ALL THAT APPLY)
1 Purchase supplies
2 Pay for a service (e.g., transportation, meals)
3 Hire a person to assist with caregiving activities or tasks
4 Pay for Respite Services
5 Other (please describe): ________________
6 Don’t know
Now,
the next questions ask you to think back to all
of the caregiver support services you have received (e.g., help
connecting to services/resources, respite care, education/training,
counseling/support groups, and supplemental service such as
transportation, nutritional supplements, assistive devices, such as
canes or walkers, stipends) —that you as the caregiver, or the
person you care for, have received in the last 12 months.
In the last 12 months, was there a time when you could not receive the services you needed?
1 Yes
2 No
22a. If YES, which services were you unable to receive?
(CHECK ALL THAT APPLY)
1 Help connecting to services and resources for the adult care for
2 Help connecting to services and resources for children I care for
3 Respite care
4 Caregiver training, education, counseling, or support groups
5 Supplemental services
22b. If YES, what were the reason(s) you were not able to receive the service(s)? (CHECK ALL THAT APPLY).
1 Service was not available in my area
2 There was a waitlist to receive the service
3 Unable to schedule at a convenient time
4 Provider cancelled or did not show up
5 Lack of transportation to access service
6 Other (please describe): ____________________
7 Don’t know
The
questions in this section ask about how the caregiver support
experiences have affected your life.
As a result of the caregiver support services do you:
(CHECK ONE BOX ON EACH LINE) |
Yes |
No |
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Not Applicable |
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Have the caregiver support services you’ve received helped you to provide care for a longer period of time than would have been possible without these services?
1 Yes, definitely
2 Yes, probably
3 No, probably not
4 No, definitely not
5 Don’t know
Would the person you care for have been able to continue to live in the community (outside of a nursing home or other care facility) if you had not received caregiver support services?
1 Yes, definitely
2 Yes, probably
3 No, probably not
4 No, definitely not
5 Don’t know
6 The person I care for does not live in his/her own home
To what extent have the caregiver support services improved your quality of life?
1 Very much
2 Somewhat
3 Very little
4 Not at all
The
questions in this section ask about some potential benefits and
challenges you may have when providing care to the person you care
for.
Section 4. Caregiver Health
In your experience as a caregiver, how important is each of the following?
(CHECK ONE BOX ON EACH LINE) |
Not at all Important |
Not Important |
Somewhat Important |
Very Important |
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Do you have any kind of health problem, physical condition, or disability that affects the amount or type of care that you can provide?
1 Yes
2 No
3 Don’t know
How physically difficult would you say it is for you to provide care to the person you care for?
1 Not at all difficult
2 A little difficult
3 Somewhat difficult
4 Very difficult
How emotionally difficult would you say it is for you to provide care to the person you care for?
1 Not at all difficult
2 A little difficult
3 Somewhat difficult
4 Very difficult
How financially difficult would you say it is for you to provide care to the person you care for?
1 Not at all difficult
2 A little difficult
3 Somewhat difficult
4 Very difficult
Has your caregiving ever interfered with your employment?
1 Yes, but I continue to work
2 Yes, I took a leave of absence but went back to work
3 Yes, I reduced my hours as a result
4 Yes, I retired early as a result
5 Yes, I quit work as a result
6 Yes, I lost my job as a result
7 No
8 I was never employed while providing care
Section 5. A Little About You!
What is your age? _______
What is your sex?
1 Male
2 Female
3 Other
What is your race? (CHECK ALL THAT APPLY)
1 White
2 American Indian or Alaska Native
3 Asian
4 Black or African American
5 Native Hawaiian or Other Pacific Islander
Are you of Hispanic, Latino/a, or of Spanish Origin?
1 Yes
2 No
What is your marital or relationship status?
1 Married
2 Partnered
3 Widowed
4 Divorced
5 Separated
6 Never married
In general, how would you rate your overall health?
1 Excellent
2 Very good
3 Good
4 Fair
5 Poor
Thank
you very much for completing this survey. Please return it in the
envelope provided to:
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is xxxx-xxxx. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, per year, including the time to review instructions. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to [title], [address, city, state, zip].
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Clarke, Gretchen |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |
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