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AgingInfoUSA Employee Survey
Required Required Question(s)

 

You're company is committed to finding ways to educate their employees on resources related to aging and family caregiving.  By completing this survey you will assist AgingInfoUSA in determining the type of programs and events would have the greatest positive impact on both your work and home life. 

The information you provide is confidential.  There is no system in place to track your personal information or identification.  Your company is only interested in putting educational programs and optional resource information in place to assist employees who are currently caring for an aging loved one or are interested in information related to caregiving and aging issues.


The survey is set up to intentionally require an answer to each question.  Thank you for taking the time to complete the survey.
 
Required 1.

Have you cared for an elderly family member or friend?
I am currently caring for someone.
I have cared for a family member or friend in the past.
I will be caring for a family member or friend in the near future.
I know someone who is caring for a family member or friend.
I am not, nor do I know anyone caring for a family member or friend.
  • Comment:

  • 500 characters left.
Required 2.

Do you ever feel overwhelmed by the demands of work, raising children and the growing needs of an elderly loved one?
Rarely
Occasionally
Often
Almost daily
Never
  • Comment:

  • 500 characters left.
Required 3.

Are your weekends spent taking an elderly loved one shopping or fixing up their home?
Rarely
Occasionally
Often
Never
  • Comment:

  • 500 characters left.
Required 4.

Are you concerned that you may need to take time off of work to take an elderly loved one to the doctor?

Rarely
Occasionally
Often
Never
  • Comment:

  • 500 characters left.
Required 5.

Are you concerned that you may need to take time off of work (such as FMLA leave) to care full-time for a loved one?

Rarely
Occasionally
Often
Never
Other  
  • Comment:

  • 500 characters left.
Required 6.


Do you assist an elderly family member with any of the following: (Check all that apply)
Help with tracking of bills, checks, or other financial matters.
Preparation of meals, help with laundry, and help cleaning the house.
Help with medical needs such as changing bandages or helping take their medications.
Assisting them with dressing, eating, bathing, or getting to the bathroom
They do not need my assistance with any of these items
Other  
  • Comment:

  • 500 characters left.
Required 7.

Are you aware of services available to assist you as you age?
I am very aware of the services that will help me as I age
I know about some services but don't know how to coordinate them if I needed them
I am vaguely aware that there are services that would benefit me
I have no clue where to even begin to look for services to help me as I age
Other  
  • Comment:

  • 500 characters left.
Required 8.

When you are looking for information about any service or subject how do you research it? (Check all that apply)
Ask a friend
Use the Internet
Try to find books/magazines to read up on the subject
Contact my Human Resources Manager for possible resources
Contact a professional in that industry
Other  
  • Comment:

  • 500 characters left.
Required 9.

Which of the following would you be interested in if they were available at your workplace? (Check all that apply)
Workshops/seminars on elder care issues
Brochures, pamphlets, or other written information
Care coordination specifically created for the person you are caring for by a health care professional
Caregiver support group
Downloadable e-book on how to talk to an aging loved one about care options
Internet references on caregiving
Help in determining long term care options
Other  
  • Comment:

  • 500 characters left.
Required 10.

Which of the following have you or someone you know experienced as a result of caregiving responsibilities?  (Check all that apply)
Finding trained & reliable home care providers
Finding affordable residential care
Finding what services are available in my community
Having enough money to pay for care
Understanding government programs such as Medicare/Medicaid
Finding out about legal options
Getting cooperation & assistance from other family members
Managing with a break down in care arrangements
Getting information about the illness/disability of the person(s) I care for
Ensuring my family member's safety
Identifying available transportation resources
Communicating with professional resource providers
Planning for end-of-life care choices
Balancing other family responsibilities, i.e., children, aging family, siblings
Dealing with dangerous, unwanted, or difficult behaviors of the care recipient
Involvement in decisions about the care recipient's medical treatment
Modifying a home to meet care requirements
Adjusting my work schedule, meeting my work responsibilities.
Meeting my personal needs such as personal time, exercise.
Other  
  • Comment:

  • 500 characters left.
Required 11.

Which of these topics would you be interested in attending if offered as a lunchtime educational program at your place of work? (Check all that apply)
Resource to help me take care of myself while caring for others
Legal/Financial Planning Services
Reverse Mortgage Information
Senior Housing and Facility Options
Home Health Care and Rehabilitation Services
Medical Care Coordination and Billing Assistance
Long Term Care Insurance
Medicare/Medicaid and other Health Insurance Options for Seniors
Health and Wellness Information
Veterans Assistance Programs
End of Life Care and Funeral Pre-planning
Educational Information on Alzheimer's Disease and Care Options
Hearing/Vision Loss
Services available for shopping/food delivery
Fall Prevention and Safety in the Home
Healthy Living as We Age
Home Modification to help Seniors become more independent
Prostate Cancer Education
Diabetes, Kidney Disease and Dialysis Education
Disease specific educational program (please specify in comment area)
Other  
  • Comment:

  • 500 characters left.