Caregiver Survey Form
Please help us understand your experiences and needs as a caregiver by answering the following questions.
What is your name?
What is your email address?
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your relationship to the person you are caring for?
How long have you been providing care? (in years)
How often do you provide care? (hours per week)
What is the living situation of the person you care for?
Living with me
Living independently
Living in assisted living
Living in nursing home
What types of care do you provide? (Select all that apply)
Personal care (bathing, dressing)
Medical care (medications, treatments)
Emotional support
Household tasks
Transportation
Financial management
On average, how many hours per day do you spend caregiving?
How has caregiving impacted your health?
No impact
Some impact
Significant impact
Prefer not to say
Do you provide emotional support to the person you care for?
Yes
No
What self-care activities do you engage in? (Select all that apply)
Exercise
Hobbies
Socializing
Meditation
None
What information do you need more of? (Select all that apply)
Medical care
Legal rights
Financial assistance
Support services
Respite care
Are you aware of available caregiver resources?
Yes
No
Do you experience financial strain due to caregiving?
Yes
No
Do you need guidance on caregiving tasks?
Yes
No
Do you use technology to assist with caregiving?
Yes
No
Are you interested in learning more about caregiving technologies?
Yes
No
Would you like to join a caregiver support group?
Yes
No
What kind of encouragement or support would be most helpful to you?
Submit
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