PA CareKit Evaluation Study - Caregiver Interest Form

Are you providing unpaid care for a family member or loved one?

You may be eligible to participate in a study evaluating the PA CareKit (pa.gov/carekit), a collection of tools, information, and support to help caregivers learn more, plan ahead, or catch their breath.

Participants will receive free one-on-one support from a trained CareKit Coach who can help you navigate caregiving challenges, explore available resources, and use the CareKit tools.

Your participation will help improve supports for caregivers across Pennsylvania.

Who Can Participate:

Older adults caring for a spouse or partner
Adults caring for an aging parent, relative, friend, or neighbor
Grandparents raising grandchildren (kinship caregiver)
People caring for adults with intellectual or developmental disabilities

What Participation Involves:

Work with a CareKit Coach for personalized guidance and support
Use tools from the PA CareKit designed to help caregivers plan, manage care tasks, and find resources
Complete brief surveys or check-ins about caregiving experiences and wellbeing
Share feedback on how the CareKit could be improved

If you are interested in participating or learning more, please complete the interest form.

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

Address (We would like to send printed CareKit Materials)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Spousal Caregiver: A husband, wife, or partner who provides care for their loved one.Parent Caregiver: A parent caring for a child with disabilities or chronic health conditions.Grandfamily Caregiver: A grandparent raising and caring for their grandchildren.Working Caregiver: Someone who balances employment with caregiving responsibilities.Long-Distance Caregiver: A caregiver who supports the person they are caring for from afar.Sandwich Caregiver: A parent raising their children while also caring for an aging parent.Dementia Caregiver: A caregiver who supports someone living with dementia.Youth Caregiver: A person in their teens or twenties who provides care for a family member.

YesNo

PhoneVirtualEither

What is your preferred or primary language?*

YesNo