Austin and Travis County Need YOUR Help to Plan for the Future
Please complete the following survey if you provide care to SENIORS (ages 55 or older) in the community. (If a question does not apply to you, please skip to the next question)
Please tell us about yourself:
1. I am (check one):
- A Formal Caregiver (Professional/Volunteer)
- An Informal Caregiver (Family/Layperson)
2. I
with the person for whom I provide care.
3. I am
4. I am
- 18-29
- 30-39
- 40-49
- 50-59
- 60-69
- 70-79
- 80 years or older
5. I am
- African-American (Black)
- Hispanic
- Caucasian (White)
- Asian American
- Other _________________________________________
6. My total household income per month is: (Please include all sources of income including social security, your spouse's income, and any extra income.)
- Less than $695
- $696 to $1042
- $1043 to $1390
- $1391 to $2085
- $2086 to $2780
- $2781 and over
7. In a typical week I spend ____________hours caring for a senior.
8. Who do you usually turn to when you need help as a caregiver?
- Relative
- Friend/ Neighbor
- Professional Caregiver
- Social Worker
- Program/Agency
- Don't have anyone to help
- Other (please describe)_____________________________________________
9. Has your language or culture ever made it difficult for you to obtain services to care for your client or family member?
- Never
- Rarely
- Sometimes
- Many times
- Most of the time
10. As a caregiver, do you have needs that are not being met? (Please describe)
11. What type(s) of care do you provide to your client or family member?
- Transportation
- Home Repair
- Personal Care Assistance
- Groceries/meals
- Housecleaning
- Money Management
- Legal Assistance
- Caregiver respite
- Social Activities
- Other (please describe) _______________________________
12. Would you find a volunteer or professional caregiver to do what you do now if you had additional resources or services available to you?
- Yes
- No
- Don't Know
- Not Applicable
Please tell us about the person you care for:
1. I am a caregiver for:
- My Wife or husband
- My Parent or In-law
- Other (please specify)______________________
2. The person I care for is:
3. The person I care for is:
- 55-59 years old
- 60-69 years old
- 70-79 years old
- 80+years old
4. Does the person you are caring for use or receive any of the following? (Check all that apply)
- Transportation
- Public Housing
- In-Home Care
- Groceries/meals
- Home Repair
- Medicare
- Legal Assistance
- Housecleaning
- Medicaid/MAP
- Social Security Checks
- Caregiver Respite
- Medigap/extra insurance
- Food Stamps
- Social Activities Help paying rent/other bills
- NONE
- Other (please describe) ________________________
5. What kinds of services does the person you're caring for need that he/she isn't getting now? (check all that apply)
- Transportation m Public Housing
- In-Home Care
- Groceries/meals
- Home Repair m Medicare
- Legal Assistance m Housecleaning
- Medicaid/MAP
- Social Security Checks
- Caregiver respite
- Medigap/extra insurance
- Food Stamps
- Social Activities
- Help paying rent/other bills
- NONE
- Other (please specify) _____________________________
6. Of the services listed above, which three (3) are the most important to your client or family member?
7. What could be done to make these services better or easier to use?
8. What are the biggest problems that keep the person you're caring for from getting what he/she wants or needs?
9. Which programs or agencies help the person you're caring for the most?
Thank you for completing this survey.
This survey is part of a community assessment, the Aging Services Environment Scan project, being conducted by St. David's Foundation, United Way/Capital Area and Travis County Health and Human Services & Veteran's Services.
