BBAMEC Caregivers Survey

BBAMEC Caregivers Survey
1. Have you been or are you a caregiver for someone who is ill or shut in?

Yes No
2. Do you currently feel unprepared as a caregiver?

Yes No
3. How has taking care of your family member/friend affected your health?

My health is better My health has not been affected My health is worse
4. As a caregiver, which responsibilities listed below would you need information about or support/assistance with? (Choose all that apply)

A. Keeping the person, I care for safe at home B. Managing challenging behaviors C. Easy activities I can do with the person I care for D. Managing incontinence or toileting issues E. Moving or lifting the person I care for F. Balancing my work and family responsibilities G. Finding time for myself H. Choosing an assisted living facility/ nursing home I. Choosing a home care agency or in-home assistance J. How to talk with doctors and other healthcare professionals K. Managing my emotional and physical stress L. Making end-of-life decisions/will preparation/estate planning
5. On a scale from 1 to 5, where 1 is not a strain at all and 5 is very much a strain. How much of a physical strain would you say that caring for your family member/friend is for you?

1

2

3

4

5

1 is No strain , 5 is Lots of strain
6. As a caregiver, would you like to be a part of a Support group?

Yes No
7. Are you afraid of what the future holds for your loved one without the needed support?

Yes No
8. Would you like someone to contact you and discuss how the Caregivers ministry can assist your family or someone you know who requires assistance?

Yes No
9. How many hours per day do you need assistance?
10. Do you have other support?

Yes No
11. Would you be willing to volunteer on occasion to sit with a sick or shut in member?

Yes No
Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State

Zip Code
Should be Empty: