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CAREGIVER INFORMATION

FIRST NAME:*  LAST NAME:*  E-MAIL ADDRESS:*  PHONE NUMBER:*  FAX NUMBER:  ORGANIZATION:  TITLE:  ADDRESS 1:  ADDRESS 2:  CITY:  STATE:  ZIP CODE:

PLEASE ANSWER ALL QUESTIONS (Questions courtesy of Kansas State Research & Extension and Sedquwick County Faculty and Staff)

1.  I can't get enough rest. Seldom Sometimes Often Usually Always 2.  I don't have enough time for myself. Seldom Sometimes Often Usually Always 3.  I don't have enough time to be with other family members because of my caregiving. Seldom Sometimes Often Usually Always 4.  I feel guilty about my situation. Seldom Sometimes Often Usually Always 5.  I don't see old friends and get out much anymore. Seldom Sometimes Often Usually Always 6.  I have conflicts with the person in my care. Seldom Sometimes Often Usually Always 7.  I have conflicts with other family members. Seldom Sometimes Often Usually Always 8.  I cry every day. Seldom Sometimes Often Usually Always 9.  I worry about having enough money to make ends meet. Seldom Sometimes Often Usually Always 10.  I don't feel I have enough knowledge or experience to give care, as I would like. Seldom Sometimes Often Usually Always 11.  My own health is not good. Seldom Sometimes Often Usually Always 12.  Caregiver responsibilities are forcing me to be absent from work and experience a loss of productivity. Seldom Sometimes Often Usually Always