FSCA - Caregiver Online Survey

FSCA CAREGIVER - ONLINE SURVEY
5409 - 50th Avenue
Red Deer, AB T4N 4B7
Phone: 403-309-8205 Fax: 403-343-6407
E-mail: fsca@fsca.ca

Dear Survey Recipient,
Family Services of Central Alberta is committed to continue to develop and provide programming that is relevant to the emerging needs of persons in the communities we serve. Caregiving is one of the roles that many people are currently performing or anticipating becoming involved in.
The attached survey will allow us to understand and support the needs of caregivers and to adapt current programming and explore new ways of providing information, connections within the community and easing caregiver strain.
We invite you to take a few minutes and complete this survey.
We would also invite you to take some time to look at our current programming that may be of interest and help to you as a caregiver, these are: Take Care, Adult Day Program and Home Support.
The Survey is designed to gather information from your perspective as a caregiver. This will assist Family Services of Central Alberta in determining if there are additional ways that we can support you or find the resources to support you and your family in the significant role you play in your loved ones life. Thank you for your time.
Although all questions are optional, we appreciate as much information as you can provide. Information provided is confidential and will be recorded as aggregate data. No individuals will be identified. Results will be published on www.fsca.ca.

1. Your Gender: Male Female

2. Your Birthday: (Year/Month/Day)

3. What city or town do you live in?

4. Do you currently, or have in the past, cared for an adult family member or friend with a health problem or disability or any adult age 60 or older? (please check all that apply).

Adult(s) aged 18-59 Adult(s) aged 60 or older I have not cared for an adult with a health problem or disability or an older adult.

5. Do you anticipate needing to care for an adult family member or friend with a health problem or disability or any adult age 60 or older in the NEXT FIVE YEARS? YES NO

6. How many persons do you anticipate providing for?

7. How are these persons related to you? (Please check all that apply)

Spouse/Partner Mother/Father Mother-in-law / Father-in-law Grandparent Son/Daughter Other Relative Friend/Neighbour Other (please specify):

8. Do any of these persons live with you? YES NO

9. What kind of assistance do you provide? (Please check all that apply)

Cooking, laundry or house cleaning

Home maintenance or repair

Transportation

Interpreter

Feeding, bathing, toileting, dressing or grooming

Assistance in transferring

Administering medications

Managing the person's financial affairs

Direct financial support

Providing emotional reassurance

Arranging and monitoring outside help or services
Other (please specify):

10. Which of these concerns have you experienced as a result of your caregiving responsibilities? (Please rate each concern.)

a) Finding Home Care

b) Finding Home Support

c) Finding Services in General

d) Financial Burden

e) Understanding Government Programs

f) Finding Out About Legal Options

g) Getting Cooperation & Assistance From Other Family Members

h) Dealing With a Break Down in Care Arrangements

i) Getting Information About the Illness/Disability of the Person(s) I Care For

j) Ensuring the Care Recipient's Safety

k) Identifying Available Transportation Resources

l) Finding Culturally-Sensitive Resources

m)Communicating with Professional Resource Providers

n) Doing End-of-Life Planning

o) Balancing Other Family Responsibilities, e.g. children

p) Dealing with Dangerous, Unwanted, or Difficult Behaviours of the Care Recipient

q) Involvement in Decisions About the Care Recipient's Medical Treatment

r) Modifying my Home to Meet Care Requirements

s) Adjusting my Work Schedule, Meeting my work Responsibilities

t) Meeting my Personal Needs such as Personal Time

u) Other (please specify):

11. To what extent do you experience the following as a result of your caregiving responsibilities? (Please rate the extent of each concern.)

a) Physical strain/fatigue

b) Financial strain

c) Emotional upset, guilt

d) Interference with social life

e) Interference with family relationships

f) Interference with free time

g) Interference with work

h) Physical health changes

i) Reluctance to ask for help

j) Unappreciated

k) Other (please specify):

12. To what extent do you agree/disagree with the following statements? (Please rate).

a) I have more caregiving responsibility than I can handle.

b) I don't have enough time for myself due to my caregiving responsibilities.

c) I cannot get a restful night sleep.

d) I have a good balance between work, family & personal responsibilities.

e) I am doing a good job of meeting work, family & personal responsibilities.

f) I feel in control of the important things in my life.

g) I feel confident in my ability to handle my personal problems.

h) I feel that any difficulties are up so high that I cannot overcome them.

i) Other (please specify):

13. During the past 12 months, you have considered a reduced work schedule because your caregiving responsibilities or early retirement? YES NO

14. Which of the following resources do you currently use, or would you find useful if they were available? (Please check all that apply).

a) Workshops/seminars on adult care issues

b) Brochures, pamphlets, or other written information

c) Internet references on caregiving

d) Caregiver support group/counselling

e) Help locating services

f) Legal consultation

g) Equipment/home adaptation

h) Help determining long term care options

i) Help with admitting care recipient to long term care facility

j) Social support following the death of the care recipient

l) Other (please specify):

15. What community and/or in-home services do you currently use, have used or would you find helpful if they were available? (Please check all that apply).

a) Adult Day Support Program

b) Personal Care/Home Care

c) Home Support/Housekeeping

d) Counselling

e) Education/Training

f) Form completion/letter writing

g) Home delivered meals

h) Home repair services

i) Hospice

j) Health promotion, e.g.exercise/socialization

k) Information service

l) In-Home visiting

m) Legal service

n) Respite care

o) Shopping assistance

p) Support groups

q) Translation services

r) Transportation/escort

s) Other (please specify):

16. Have you ever been involved with a caregiver support group? YES NO If YES, what did you enjoy about it?

17. At this time, would you like to be involved in a caregiver support group? YES NO If NO, why not?

18. Would you prefer to be involved in a peer led support or a support group with a facilitator? Peer Led Facilitator

19. How often would you like to meet as a caregiver support group?

Weekly
Bi-Weekly
Monthly
Every 3 months
Other (please specify):

20. What would your ideal caregiver support group look like? (Please be specific - guest speakers, information on... etc.)

21. Please provide any additional comments you might have about your past, present and anticipated caregiver needs.

22. Would you like to be on our mailing list to receive more information? YES NO

CONTACT INFORMATION (OPTIONAL)

Name:

Address:

Postal Code:

Phone Number:

E-mail: