Connect the DOTS Caregiver Survey

Thank you for taking a few moments to complete this survey. It will help the community-wide Connect the DOTS team determine what kinds of support are most needed with those who provide care for our families and friends. We appreciate your taking about 5 minutes to provide this input; please do so by Friday 17 September. Thank you again!

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* 1. For how many people do you currently provide care?

More than 2

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* 2. For whom do you currently provide care? (check all that apply)?

Elderly adult

Mentally and/or physically disabled adult

Mentally and/or physically disabled child under age 18

Adult with chronic illness

Adult with terminal illness

Child under age 18 with chronic illness

Child under age 18 with terminal illness

Adult or child vulnerable to COVID-19

Other (please specify)

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* 3. How often do you provide care?

Every day

Several days a week

As needed

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* 4. Does the person for whom you provide care live in the same home with you?

Yes

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* 5. Why are you providing this care? (check all that apply)

Person(s) receiving care cannot afford other options

Person(s) receiving care does not want anyone else to care for them

I feel I can do a better job because of my connection to the person(s) receiving care

I feel it is my responsibility

I want to provide the care

The person(s) for whom I care are concerned about the possibility of exposure to the COVID-19 coronavirus

Unaware of other care options

Other (please specify)

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* 6. Were you providing this care before the COVID-19/coronavirus pandemic?

Yes

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* 7. Do you have the ability to get away from caregiving when needed, such as for grocery shopping or just when you would like to have a break?

Yes, but not often enough

Yes, whenever needed

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* 8. How long have you been providing care?

Less than six months

six months - 1 year

1-2 years

Over 2 years

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* 9. How long do you think you will continue to provide care?

Less than six months

six months - 1 year

1-2 years

Until the COVID-19/coronavirus pandemic is considered under control

Indefinitely

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* 10. What challenges do you have in providing care? (check all that apply)

Transportation for yourself

Transportation for the person(s) for whom you are providing care

Adequate finances to provide care

Physical barriers, such as inconvenient living space, difficult stairs, bathing/toileting, structural barriers, etc.

Balancing caregiving with job/work

Lack of knowledge of community resources to aid caregivers

General stress

Concern of exposure to COVID-19/coronavirus in proving help for the person for whom I'm caring (not necessarily from the person you're caring for, but in helping them to appointments, shopping for them, etc.)

Other (please specify)

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* 11. How concerned are you as of today about the impact of the COVID-19/coronavirus pandemic on your ability to provide care?

Very concerned

Concerned

Somewhat concerned

Not concerned

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* 12. Do you work outside the home?

Yes, full-time

Yes, part-time

No, as a result of the COVID-19 pandemic

No, but not as a result of the COVID-19 pandemic

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* 13. Would you be interested in being part of a group of caregivers who would provide support for each other and share information about available resources for caregivers?

Yes

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* 14. Would you be able to attend in-person meetings of such a group?

Yes

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* 15. Would you be able to attend online meetings (Zoom or similar) of such a group?

Yes

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* 16. (If yes to both #14 and #15) Which type of meeting would you prefer?

In person

Zoom or similar

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* 17. (If yes to both #14 and #15) What days/times would work best for you?

Weekdays during the day

Weekday evenings

Weekend days

Weekend evenings

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* 18. (If no to both #14 and #15) Would you still be interested in being informed of caregiver group activities, including info about available caregiver resources?

Yes

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* 19. How many people live in your household, not including any person(s) for whom you are a caregiver?

2-4

5-6

Over 6

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* 20. Do you have any person(s) over age 65 living with you, not including any person(s) for whom you are a caregiver?

Yes

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* 21. Do you have any person(s) under age 5 living with you, not including any person(s) for whom you are a caregiver?

Yes

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* 22. Do you have any person(s) age 6-18 living with you, not including any person(s) for whom you are a caregiver?

Yes

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* 23. What is your zip code?

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* 24. If you would like to be included in future communications about caregiver resources, including a caregiver support group, please provide your name and an email address and/or phone number; this information will not be used for any other purpose.