Form
Caregiver Survey
Which of the following best describes your current relationship status?
Single, never married
Married
Divorced
Separated
Domestic Partnership
Prefer not to say
Do you have children?
Yes
No
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How old is/are your parent(s)?
60-69
70-79
80-89
Over 90
Which accurately describes your parent’s current status?
My parent/s is/are healthy and lives independently with little need for support
My parent/s is/are healthy but starting to need some assistance
My parent/s has a medical issue that requires full time support
Other
Are you the person in your family with primary or significant care responsibilities for your aging parent. Primary care responsibilities can mean anything from you are the person who is called first in an emergency to you are living with and ensuring the care and safety of your parent(s).
Yes
No
I share responsibility equally with other family caregivers
It's complicated
How long have you been in this role?
Less than five years
Five to ten years
Ten to fifteen years
More than fifteen years
What has been the most challenging caregiver issue you have faced so far, either for your parent or yourself?
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Have you begun planning for your own elder care?
Yes
No
Have you done any of the following for yourself?
Will/ Trust
Long Term Care
Researched 55+ / retirement communities
Other
If you responded other, what additional steps have you taken?
What is your top concern about getting older?
Have you had conversations with other family members about your wishes as you get older?
Yes
No
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Where do you find information about elder care? (Select all that apply)
Internet searches
AARP resources
Information shared by friends, relatives
Medical providers
Other
If you selected other, what additional resources do you use?
How do you prefer to consume information?
Newsletter
Social Media (instagram, facebook, twitter)
Podcasts
YouTube videos
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What is your gender?
Female
Male
Transgender
Non-binary
Prefer not to say
What age range do you fit in?
Under 40
40-45
45-50
50-55
55-60
Over 60
Which race/ethnicity best describes you?
American Indian or Alaska Native
Black or African American
Hispanic
White/Caucasian
Multiple ethnicities
Prefer not to say
What is the highest level of education you've completed?
Some high school but no diploma
High school diploma or equivalent
Some college but no degree
2-year college degree
4-year college degree
Graduate level degree
Other
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