Financial Impact of a Caregiving Experience Survey

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* 1. On a scale from 1 to 5, with 1 being the least stressed and 5 being the most stressed, how stressed are you?

	1 Least Stressed	2	3	4	5 Most stressed
How stressed are you?	How stressed are you? 1 Least Stressed	How stressed are you? 2	How stressed are you? 3	How stressed are you? 4	How stressed are you? 5 Most stressed

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* 2. Tell Us Your Zip or Postal Code

ZIP/Postal Code

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* 3. For whom do you care? Check as many as appropriate.

Adult child over 18

Aunt or uncle

Child under 18

Cousin

Friend

Grandparent(s)

Parent(s)

Sibling

Spouse or partner

Please feel free to share any details about your caregiving situation.

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* 4. How long have you been in a personal caregiving situation?

Less than 1 year

Between 1 and 5 years

Between 5 and 10 years

More than 10 years

My caregiving role has ended

Please feel free to share any details about your situation.

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* 5. Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple ethnicity / Other (please specify)

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* 6. What is your gender identity?

Woman

Man

Genderqueer or non-binary

Agender

Not specified above, please specify

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* 7. Do you also work? Please check as many as apply.

Caregiving is now my work

I left the workforce because of my caregiving responsibilities

I lost my job because of the pandemic

I receive reimbursement for caring for my family member

I retired

I retired early because of my caregiving responsibilities

I retired early because of the pandemic

I work for myself

I work full time

I work part time

Please share any details about your experiences that you’d like.

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* 8. How would you describe your financial situation prior to caregiving?

Strong -- I had savings and easily paid my bills on time.

Good -- I had some savings and paid my bills on time.

Fair -- I had a little bit of savings and usually paid my bills on time.

Challenging -- I didn’t have any savings and struggled to pay my bills on time.

Please share any details of your situation that you’d like.

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* 9. How would you describe your financial situation today?

Strong -- I have savings and easily pay my bills on time.

Good -- I have some savings and pay my bills on time.

Fair -- I have a little bit of savings and usually pay my bills on time.

Challenging -- I don’t have any savings and struggle to pay my bills on time.

Please share any details of your situation that you’d like.

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* 10. Which benefits and programs does your caree receive?

Medicare

Medicaid

Workman’s comp

Long-term care insurance

Insurance coverage through your employer's benefits

Veteran’s Benefits

Please feel free to share any additional details about your caree’s programs.

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* 11. How would you describe your savings for your future?

I have no savings.

I have some savings.

I have enough savings.

I have plenty of savings.

Please feel free to share any details about your situation.

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* 12. How has your caregiving experience impacted your ability to save for your future? Check as many as apply.

I have used all my savings to pay for caregiving expenses.

I have used all my savings because I had to leave the workforce as a result of my caregiving responsibilities.

I have used some of my savings to pay for caregiving expenses.

I have used some of my savings because I had to leave the workforce as a result of my caregiving responsibilities.

There’s been no impact on my savings.

Please feel free to share any details about your situation.

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* 13. How much of your own money do you use to pay for caregiving experiences on an annual basis?

Less than $1,000.

Between $1,000 and $5,000.

Between $5,000 and $10,000.

Between $10,000 and $15,000.

More than $15,000.

None.

Please feel free to share any details about your situation.

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* 14. For which caregiving expenses do you pay? (Check all that apply.)

Caregiving supplies such as incontinence supplies, wound care supplies and health care supplies

Day programs

Food

Hospital bill

Household expenses, including mortgage or rent payments, utilities, home modifications, remote health and safety monitoring devices

In-home care

Legal bills

Medications

Mental health services for you and/or your caree

Physicians

Senior care communities, including long-term care facilities

Therapists, including physical, occupational and speech therapists

Travel expenses, including costs of traveling to see a caree and for your caree’s treatments

Treatment costs

Other. Please share more in our comment field, below.

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* 15. What do you need that you can’t afford? (Check all that apply.)

A break

A more affordable house

An accessible home

Caregiving supplies such as incontinence supplies, wound care supplies and health care supplies

Clothes for myself

Day programs

Dental care for myself

Food

Food for a caree’s special diet

Glasses and/or contacts for myself

Health care (physician appointments, annual screening) for myself

Home modifications and remote health and safety monitoring devices

In-home care

Legal help

Medications

Mental health services for you and/or your caree

Placement for a caree in a senior care community, including a long-term care facility

Specialists who could help manage a caree’s disease process

Therapists, including physical, occupational and speech therapists

Travel, including costs of traveling to see a caree and for your caree’s treatments

Treatments for a caree’s disease or illness

Other. Please share more in our comment field, below.

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* 16. How comfortable do you feel about your ability to pay for your own future care?

Very uncomfortable.

Uncomfortable.

Somewhat comfortable.

Comfortable.

Please feel free to share any details about your situation.

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* 17. What would help you most? Please check as many as appropriate.

$3,000 tax credit to working family caregivers for qualified expenses

Annual stipend of $1,200

Career coaching to help re-enter the workforce after a caree’s death

Caregiving coaching

Financial coaching

Grants to pay for respite care to cover the costs of an annual two-week break

Grants to start a small business to provide flexibility and stability during and after caregiving

Monthly stipend of $250

Monthly stipend of $500

Paid leave.

Social Security credits for caring for a family member after leaving the workforce

Training on how to care for a family member

Please share additional ideas and suggestions.

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* 18. What would change for you if you had enough money to pay for today’s needs and save enough for your future?

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* 19. What is your experience trying to find help for yourself and your caree?

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* 20. Please share any experiences about the financial impact of your caregiving experience.

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* 21. Would you like to receive updates from us on our campaign to create financial security for family caregivers? If so, please share your email address, below.

Email Address

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* 22. Would you or your organization like to help with our initiative? Please share your email address, below, so we can be in touch.

Email Address