Sunday July 6, 2008
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Attention Family Caregivers: Let your opinions be heard!
Please take a moment to complete this brief survey to help us better serve your needs. Your input is important and will help us help you. The survey should take about 5 minutes to complete. We thank you in advance for your valuable thoughts.
Note: Please complete this survey only if you are a family caregiver.
1. How many times have you visited www.familycaregiving101? This is my first time 2-3 times 4-5 times 6 or more
2. How did you learn about www.familycaregiving101?
A link from another web site
An article in a magazine, newspaper, or newsletter
    Name of publication?
A friend or family member
A health professional
Other
Please click on the button that describes your opinion:Strongly
Agree		Somewhat
Agree		No OpinionDisagree
Somewhat		Disagree
Strongly
3. www.familycaregiving101 provides me with new information — things I hadn't thought of or didn't know about.
4. www.familycaregiving101 provides information that helps me be a better caregiver.
5. www.familycaregiving101 connects me to other family caregiving resources that are useful.
6. The "Financial" section of the web site is helpful to me.
7. The "Caregiving Skills" section of the web site is helpful to me.
7a. Are their other sections that you particularly found useful?
If yes — which ones?
8. www.familycaregiving101 is set up so that it's easy to find what I need.
9. There was lots of information I would like to know but could not find at www.familycaregiving101.
9a. If you strongly or somewhat agree, what additional information would you like to see?
10. If I encounter someone who is new to family caregiving, I will tell them www.familycaregiving101 is a good resource.
We'd like to hear your opinions about your experience as a family caregiverStrongly
Agree		Somewhat
Agree		No OpinionDisagree
Somewhat		Disagree
Strongly
11. As a family caregiver, I don't really need any help from other people.
12. As a family caregiver, I could use a bit more help from other people, but I feel guilty asking.
13. As a family caregiver, I know I need to take care of my own physical and mental health to be able to help my loved one.
14. I have taken actions to safeguard my own physical health.
14a. If you answered "strongly agree" or "agree" to number 14, what actions have you taken? (check all that apply.) If you answered "no opinion," "disagree somewhat" or "disagree strongly," skip to question 15.
I eat nutritious, healthy meals most of the time
I get regular exercise
I get regular health screenings (such as pap smears, mammograms, and prostate cancer exam)
I get a flu shot annually
Other
Strongly
Agree		Somewhat
Agree		No OpinionDisagree
Somewhat		Disagree
Strongly
15. I haven't yet, but I plan to take some actions in the next few months to safeguard my own physical health.
15a. If you answered "Strongly Agree" or "Agree" to question 15, please check all that apply. If you answered "no opinion," "disagree somewhat" or "disagree strongly," skip to question 16.
I plan to make sure I eat nutritious, healthy meals
I plan to get regular exercise
I plan to get regular health screenings (such as pap smears, mammograms, and prostate cancer exam)
I plan to get a flu shot annually
Other
16. I have taken actions to safeguard my own mental health.
16a. If you answered "Strongly Agree" or "Agree" to number 16, what actions have you taken? (check all that apply.) If you answered "no opinion," "disagree somewhat" or "disagree strongly," skip to question 17.
I asked a friend or family member for help with caregiving when I need a break.
I talked to someone I trust about the challenges of caregiving
I contacted an organization or agency for information or help on caregiving.
I have taken time to do something that's good for me emotionally or something I enjoy
I joined a support group or an online network or chat room to discuss family caregiving
I have seen a mental health professional
Other
Strongly
Agree		Somewhat
Agree		No OpinionDisagree
Somewhat		Disagree
Strongly
17. I haven't yet, but I plan to take some actions in the next few months to safeguard my own mental health.
17a. If you answered "Strongly Agree" or "Agree" to question 17, please check all that apply. If you answered "no opinion," "disagree somewhat" or "disagree strongly," skip to question 18.
I plan to ask a friend or family member for help with caregiving when I need a break
I plan to contact an organization or agency for information or help on caregiving
I plan to take time to do something that's good for me emotionally or something I enjoy
I plan to talk to someone I trust about the challenges of caregiving
I plan to find a support group or an online network or chat room to discuss family caregiving
I plan to see a mental health professional
Other
18. I would like to, but I have not made time to take any actions to safeguard my own health.

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