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Regional ID
 
06
 
 
Participant ID
   
 
 
Interviewer ID
 
 
 
 
 
 
Age
 
1 and Under
 
2-18
 
19-35
 
36-45
 
46-65
 
66 and Older
 
 
Sex
 
Male
 
Female
 
 
 
Age
 
1 and Under
 
2-18
 
19-35
 
36-45
 
46-65
 
66 and Older
 
 
Sex
 
Male
 
Female
 
 
 
Waiver
 
 
 
In your experience as a caregiver, what would you say is the one most positive aspect of caregiving?
 
Helping your care recipient
 
Helping your other family members
 
Feeling a sense of accomplishment
 
Caring for someone who cared for you
 
Being appreciated
 
Providing companionship for you
 
None
 
Refused
 
Don't Know
 
Other
 
 
 
Which of these difficulties is the greatest difficulty you have faced in your caregiving?
 
Creates a financial burden
 
Doesn't leave enough time for yourself
 
Doesn't leave enough time for your family
 
Interferes with your work
 
Creates or aggravates health problems
 
Affects your family relationship
 
Creates stress
 
Refused
 
Don't Know
 
Other
 
 
 
What is your realtionship to the consumer?
 
 
 
Would you say your health is good or bad?
 
Very Bad
 
Bad
 
OK
 
Good
 
Very Good
 
 
Would you say your health is good or bad? (Detail)
   
 
 
Would you say your ability of running your own life and making your own choices is good or bad?
 
Very Bad
 
Bad
 
OK
 
Good
 
Very Good
 
 
Would you say your ability of running your own life and making your own choices is good or bad? (Detail)
   
 
 
Would you say your family relationships are good or bad?
 
Very Bad
 
Bad
 
OK
 
Good
 
Very Good
 
 
Would you say your family relationships are good or bad? (Detail)
   
 
 
Would you say your relationships with friends are good or bad?
 
Very Bad
 
Bad
 
OK
 
Good
 
Very Good
 
 
Would you say your relationships with friends are good or bad? (Detail)
   
 
 
Would you say your ability of getting out and getting around is good or bad?
 
Very Bad
 
Bad
 
OK
 
Good
 
Very Good
 
 
Would you say your ability of getting out and getting around is good or bad? (Detail)
   
 
 
Would you say your overall quality of life is good or bad?
 
Very Bad
 
Bad
 
OK
 
Good
 
Very Good
 
 
Would you say your overall quality of life is good or bad? (Detail)
   
 
 
Would you say the quality of servies you recieve is good or bad?
 
Very Bad
 
Bad
 
OK
 
Good
 
Very Good
 
 
Would you say the quality of servies you recieve is good or bad? (Detail)
   
 
 
Would you say the respect you recieve from employees or service providers is good or bad?
 
Very Bad
 
Bad
 
OK
 
Good
 
Very Good
 
 
Would you say the respect you recieve from employees or service providers is good or bad? (Detail)
   
 
 
 
Do you have any unmet needs you would like to share?
 
Yes
 
No
 
Sometimes
 
Unsure/No Answer
 
 
Do you have any unmet needs you would like to share? (Detail)
   
 
 
Are there any other concerns or experiences you would like to share with us?
 
Yes
 
No
 
Sometimes
 
Unsure/No Answer
 
 
Are there any other concerns or experiences you would like to share with us? (Detail)
   
 
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