Internal Use: WPRT

 

 

 

P.O. Box 1206

Charlestown, RI02813
(401) 364-9100

Toll-free (877) 595-6227

NEW MEMBER QUESTIONNAIRE

Dear Caregiver,

Thank you for taking the time to join TCAP.Please complete the following New Member Questionnaire

and return it to the address above.We look forward to your participation.

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Paul Alper, President and Founder

Instructions: Please PRINT using blue or black ink.

 

1.†† Are you currently providing any care or assistance to a person who needs help as a result of an illness, a disability, or the aging process?

®1YES††† Ť Please continue.

®2NO††† Ť Your survey is now complete.Thank you for your interest in TCAP.

†††††††††††††††††††††††

2.†† Are you being paid to provide care?†††††††† ®2 Yes††††††† ®1 No

 

3.†† How did you hear about this panel?

 

 

 

®02 Health professional / home health aide

®07 Friend/relative

 

®30 Medical Supply Store - name:†† _____________________

®35 Telephone recruitment call

 

®31 Product insert from:†† _____________________________

®36 TCAP Postcard

 

®04 Todayís Caregiver Magazine

®37 Exceptional Parent Magazine

 

®32 TCAP panel member - please tell us who: ††††† ________________________________________

 

®33 Web site - please specify:††††† _____________________________________________________

 

®34 Caregiver group or support group - please specify group:

 

®17 NFCA

®09 WellSpouse Foundation

 

 

®10 CAPS

®40 Other: __________________________________

 

®38 Ad or article in magazine/newspaper - please specify:†††††† ______________________________

 

®39 Conference/lecture/talk - please specify:†††††† _________________________________________

 

®06 Other - please specify:††††††† _______________________________________________________

 

4.†† Please tell us how to contact you

††††† First Name _____________________Middle______________††††† Last_______________________________

††††† Address††††††† _______________________________________________________________________________

††††† City___________________________________________State_________________††††† Zip______________

 

5.†† Title (check one) ®1 Miss†† ®2 Ms.†† ®3 Mrs.†† ®4 Mr.†† ®5 Rev.†† ®6 Dr.††† ®7 Other ________________

 

6.†† Home phone number ( _______ ) _______________________________

 

7.†† E-mail address (if applicable) ___________________________________

 

8.†† Are you willing and able to participate in studies over the Internet/on line?†††† ®1Yes ††††®2No

 

9.†† Your date of birth†††† Month______ /Day______ /Year__________†† (Example 05/16/1957)

 

10.Your sex†††† ®1 Male††† ®2Female

 

 

 

11. Your marital status

®1Married or living with partner††† ®2Single, never married††† ®3Widowed††† ®4Divorced/separated

 

12.Are you employed (outside of your caregiving responsibilities)?

®1Yes, full time††††† ®2Yes, part time†††††† ®3Yes, self-employed††††† ®4No, retired†††††† ®5No, not employed

 

13.Do you own your home?††††††††† ®1Yes ††† ††††®2No

 

14.Are you a caregiver for more than one person? ††††† (as a result of illness, disability, or aging)

®1Yes†† Ť

How many do you care for?_______

®2No

 

 

 

 

First Person

Second Person

15. First name of person cared for:

_________________________

16. __________________________

a. Personís date of birth
††††††† (Example: 05/16/1957)

Month____/Day____/Year_____

a. Month____/Day____/Year_____

b. Sex

®1Male
®2Female

b.††† ®1Male
††††††
®2Female

c. Relationship to you

®1Your Spouse/Partner
®2Your Parent/In-law
®3Your Sibling/In-law
®4Your Child
®5Other Relative
®6Non-related friend
®7Your client (for paid caregiver)
®8Other (please specify)
††††††† _______________________

c.††† ®1Your Spouse/Partner
††††††
®2Your Parent/In-law
††††††
®3Your Sibling/In-law
††††††
®4Your Child
††††††
®5Other Relative
††††††
®6Non-related friend
††††††
®7Your client (for paid caregiver)
††††††
®8Other (please specify)
†††††† ††††††† _______________________

d. Is that person employed?

®1Yes, full time
®2Yes, part time
®3Yes, now on medical leave
®4No, now on disability
®5No, retired
®6No, not currently employed

d.††† ®1Yes, full time
††††††
®2Yes, part time
††††††
®3Yes, now on medical leave
††††††
®4No, now on disability
††††††
®5No, retired
††††††
®6No, not currently employed

e. Approximate height and weight
††† (please estimate)

Height:††† ____ feet††† ____ inches

Weight:†† _______ pounds

††††† Height:†††† ____ feet††† ____ inches

††††† Weight:††† _______ pounds

 

17.How many members of your household are UNDER AGE 18, (not counting you or the person you

care for)?†† (Enter #) ___ ___

 

18.How many members of your household are AGE 18 OR OLDER, (not counting you or the person you

care for)?†† (Enter #) ___ ___

 


 

**NOTE:†† PLEASE FILL OUT ALL REMAINING QUESTIONS BASED ONLY ON THE
††††††††††††††††† FIRST PERSON LISTED ABOVE (IN Q15).

 

19.What type of residence does the person you care for live in?

®1Nursing home

®3Assisted living facility

®2Private home or apartment

®4Other (please specify)__________________________

 

20.Do you and the person you care for live in the same household?††
®1Yes †††††††††††††††††† ®2No

†††††††††††††† (Skip to Q22) ††††††††††††† Í

How many adults age 18 or older live with the care recipient in
his/her household?
(Enter #) ___ ___OR®98Many (group/institutional setting)

†††††††††††††††††††††††††††††††††††††††††††††††

21.How long does it typically take to travel to the residence of the person you care for?

®1Less than
†††††† 20 minutes

®220 minutes †††††† to 1 hour

®3Over 1 hour
†††††† to 2 hours

®4Over 2 hours †††††††††

 

 

22.What is the nature of the condition(s) of the person you are caring for?
(Please read all conditions and check ALL that apply)

®1

ALS (Lou Gehrigís Disease)

®26

Heart disease/angina

®2

Alzheimerís/dementia

®27

High blood pressure

®3

Amputation

®28

HIV/AIDS

®4

Anemia

®29

Impaired hearing

®5

Arthritis

®30

Impaired vision

®6

Asthma/bronchitis

®31

Incontinence: bladder

®7

Autism

®32

Incontinence: bowel

®8

Birth defects

®33

Kidney disease

®9

Bone/joint fractures or repairs

®34

Mental illness

®10

Cancer

®35

Mental retardation/developmental disabilities

®11

Catheter

®36

Multiple Sclerosis (MS)

®12

Cerebral Palsy (CP)

®37

Nutritional deficit

®13

Chronic pain

®38

Osteoporosis

®14

Circulation problems/vascular disease

®39

Ostomy

®15

Clinical depression

®40

Parkinsonís Disease

®16

Congestive heart failure

®41

Pulmonary disease/Emphysema

®17

Crohnís Disease

®42

Spina Bifida

®18

Cystic Fibrosis

®43

Spinal cord injury

®19

Diabetes

®44

Stroke/TIA

®20

Downís Syndrome

®45

Urinary tract or prostate disorder

®21

Epilepsy/seizures

®46

Wounds/skin breakdown/decubitus ulcers

®22

Feeding/gastrostomy tube

®47

Other(s): __________________________

®23

Functional decline

 

†††††††††††††† __________________________

®24

Gastrointestinal disorder

 

†††††††††††††† __________________________

®25

Head injury

 

 

 

 


23.How long have you been providing care to this person?

_____Years††† _____Months

 

 

24.Approximately how many hours per week do you spend actively providing care?†††

______ Hours per week†† OR†† ®998Provide constant care

 

 

25.Which of the following best describes the mobility of the person you care for? (Please check one)

®1Able to walk unassisted

®3Can walk with assistance of a person/walker/cane

®2Needs wheelchair/stroller

®4Confined to bed

 

 

26.Which activities do you assist with or provide? (Check all that apply)

®1†† Bathing

®13Physical therapy/exercise

®2†† Bill paying/financial matters

®14Recreation

®3†† Doctor/therapy visits

®15Respiratory care/therapy

®4†† Dressing/grooming

®16Shopping

®5†† Emotional support

®17Skills training

®6†† Housekeeping

®18Special equipment maintenance

®7†† Incontinence/pericare

®19Toileting (bedpan or toilet)

®8†† Meals/feeding

®20Transferring (e.g., moving from bed to chair)

®9†† Meals/preparation

®21Transportation

®10 Medication administration

®22Walking

®11 Medical care/monitoring

®23Other(s):†† _______________________________________

®12 Oral care

††††††††††††††††††††††† _______________________________________

 

27.Does someone else, besides you, provide any of the types of care listed above?
®1Yes††††† ®2No

Í

Who provides that care?(Check all that apply and enter approximate hours/week)

®1Other family member(s)___ ___ Hours per week

®2Paid professional/paraprofessional(s)___ ___ Hours per week

®3Other person(s) - neither a relative nor paid professional___ ___ Hours per week

®4Adult day care___ ___ Hours per week

®5School / Work programs___ ___ Hours per week

 

28.What is the HIGHEST level of education completed by yourself and by the person you care for?(Please check one in each column)

Education

Yourself

Person you care for

Less than high school...........................

®1

®1

Graduated high school/GED..................

®2

®2

Some college.......................................

®3

®3

Graduated college................................

®4

®4

Post graduate or professional degree.....

®5

®5

 


29.What is the yearly total income of your household?(Include care recipientís income if s/he lives with you.Otherwise, report his/her income separately in the second column)

Yearly Income

 

Your Household

Care Recipientís Household
(if not living with you)

Under $30,000.....................................

®1

®1

$30,000 to under $50,000......................

®2

®2

$50,000 to under $70,000......................

®3

®3

$70,000 or more...................................

®4

®4

 

Thank you for joining The Caregivers Advisory Panel.

TCAP is dedicated to conducting research that will provide information to manufacturers and service providers that will lead to innovation and improved products, services, programs and support for you and the millions of other Americans who are involved in family caregiving.
By sharing your needs and opinions, you can impact the way products and services are designed!