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CAREGIVERS SURVEY

NOFEC advocates for the caregiver with the caregivers’ needs placed first. We consciously choose to network with other organizations to avoid duplication of programs and to expand in work ethics and collaboration that generate a win-win situation for all who are involved.

With this in mind, our survey is aimed at finding out what caregivers really need and want. Your information remains private, yet the results will be combined to make better informed decisions in the ways that we can reach out to provide education, support, respite and much more.

Our membership is free to caregivers and your name and address are required because we will be mailing our quarterly newsletter to you via regular mail to your residence.

In order to provide membership free to you, we hope that you will answer our survey in good faith so that we will gain further insight into your needs as a caregiver and take steps to insure the realization of assisting you.
1. Please provide some information about yourself. required fields are marked with an*
First Name:*
Last Name:*
Email Address:*
Address:*
City:*
State:*
Zip:*
Country:*
2. What is your gender?
male
 female
3. What is your age group?
18-25
 46-55
 76-85
26-35
 56-65
 86 and over
36-45
 66-75
4. Are you :
single
married
divorced
widow/widower
5. What is your highest level of education?
some high school
 high school or GED equivalent
 some college
 graduate
 post graduate
6. Are you a: (check as many as apply)
Family caregiver
 Professional caregiver
 Primary caregiver
 24/7 caregiver
 Long distance caregiver
7a. Who are you caring for and how are they related to you? How old are they?
7b. What is their illness or disability? What stage are they in if this is a progressive disease?
7c. Where does the care recipient reside?
their home
your home
assisted living facility
nursing home
7d. How far does your loved one live from you?
7e. If not at your home, what type of transportation do you use?
7f. If the answer to 7c. was their home or your home do you have respite or some type of help?
yes
sometimes
not at this time
only as necessary
no (if no skip to question 8)
If yes how often?

If yes for how long?

If yes how what kind of help?
8. The person(s) I am caring for is financially (Check all that apply.) :
able to care for him/herself (selves)
protected by insurance that will cover all
protected by partial insurance
able cover partial expenses
unable to cover expenses
able to take care of him/herself (selves) depending upon life expectancy
9. Do you know about legal rights and responsibilities for yourself & the person(s) you are caring for? (Check all that apply.)
Living will
 yes no
Power of attorney
 yes no
Patients rights
 yes no
Caregivers rights
 yes no
Elder law
 yes no
10.Do you have outside emotional support for yourself?(Check all that apply.)
Psychotherapy
Psychiatry
Support Groups
Family
Friends
Other
11. What type of services do you use for the one(s) you care for?(Check all that apply.)
Senior centers
Respite
Meals-on-Wheels or similar service
Access-a-ride or similar service
Adult day care
Volunteers
Other
12. The care needs of the person(s) I am caring for are:(Check all that apply.)
Daily needs
Companionship
Recreational activities
Nursing care
Rehabilitation
Transportation
Emergency care
Support in end of life issues.
Other
13a. List the main difficulties you experience as a caregiver.
13b. Briefly describe how your overall general health and emotional health have been since you became a caregiver.
13c. List the main difficulties your loved one has with his or her illness or disability which affect you as well.
14. Are you willing to discuss the final stages your care recipient(s) will be experiencing if their illness is terminal.
yes
no
maybe
Please explain
15. if you are a family caregiver and your loved one(s) is (are) terminal are you familiar with what is necessary to complete business affairs and make funeral arrangements etc.
yes
no
maybe
If no or maybe, please expand on your needs
16. How did you first learn of NOFEC ?
Search Engine
 Referral / link from another site
 'Tell A Friend' referral
 Empowering Caregivers site
 Forwarding of Empowering Caregivers' Newsletter
Articles on the Internet
Articles in Magazines
Chats on AOL
Others (Please specify)
17. Type of internet connection
28 - 56 Kbps modem
 ISDN
 Cable
 DSL
 T1 or better
 Do not know
18. How would you rate NOFEC site?

On a scale of 1-10, 10 being the highest.

Please explain why.
19.The following features may be added to NOFEC in the future. Please rate their importance to you:
Very Important
Important
Somewhat Important
Not Important
• 24 hour Supervised Chat rooms
• 800 Toll Free Phone in Support Groups with professional therapists
• Specific online classes and paneled discussions with authorities in aging, health and caregiving etc.
• Downloadable educational materials
Other: please list.

20a. What is your favorite care related website ? Please list it's web address (URL).

20b. What is your main reason for using the above site?
21. What are your four main reasons for accessing care related information on the internet?



22. Your comments, opinions and suggestions are greatly appreciated.

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