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CareGiver Community Survey

Please complete all three parts of the Community Survey below. This survey is divided into three parts. After completing each part, click the Submit button before continuing to the next part.

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Part 1 – Caregivers
Part 2 – Demographics
Part 3 – About You & Community

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You must submit all three parts to complete the Community Survey.

Prefer to complete the survey on paper?

Download and print the Community Survey using the button below.

CAREGIVERS

The following questions pertain to caregivers and those for whom they care. If you do not care for anyone, please select N/A.

I need help paying for services needed by the person I care for
1-Disagree
2-Neutral
3-Agree
4-N/A
I need help locating services for the person I care for
1-Disagree
2-Neutral
3-Agree
4-N/A
I would like training on caring for someone at home
1-Disagree
2-Neutral
3-Agree
4-N/A
I need a place for the person I care for to go during the day
1-Disagree
2-Neutral
3-Agree
4-N/A
I sometimes need temporary relief from my caregiver duties (respite)
1-Disagree
2-Neutral
3-Agree
4-N/A
CAREGIVERS: Of the persons you care for, how many are over 60 years old?
1 Person
2 People
More than 2 People
N/A: Not a caregiver
CAREGIVERS: Of the persons you care for, how many are disabled?
1 Person
2 People
More than 2 People
N/A: Not a caregiver
CAREGIVERS: Of the persons you care for, how many are both over 60 years old and disabled?
1 Person
2 People
More than 2 People
N/A: Not a caregiver
CAREGIVERS: Of the persons you care for, how many are children under age 18?
1 Person
2 People
More than 2 People
N/A: Not a caregiver

Race and Ethnicity

Which of the following best describes you? Please select all that apply:

Gender Identity

We strive to create programs and services that represent and serve the full diversity of the community.


We are asking the following questions about gender, gender identity, and sexual orientation to ensure that we are meeting this goal.

Which of the following best describes you? Select all that apply:
Do you Identify as a member of the LGBTQLA+ Community

Disability Status

We strive to create programs and services that represent and serve the full diversity of the community. We are asking the following questions about disability to ensure that we are meeting this goal.

Do you have a long-lasting or chronic condition (such as physical, visual, auditory, cognitive, emotional or other) that requires ongoing accommodations for you to conduct daily life activities (Example - see, hear, speak, learn, memory)
We are interested in this data regardless of whether you typically request for/use accommodations. How do you describe your disability status? (Select all that apply)

About You and Community

Please provide the following information in the box below:


Name of Caregiver / Person Completing This Survey. Please include Name of Person You Are Providing Care For


  1. Do you know who to call for abuse, neglect, or exploitation? Yes or No:

  2. Have you ever felt unsafe or taken advantage of? Yes or No:

  3. Parish where you reside:

  4. City where you reside:

  5. ZIP Code:

  6. Is there anything else you would like for the Area Agency on Aging to know about the services you receive, services you need, or anything else that you feel is important to know?

What is your Relationship Status? Select one:
Single
Married
Divorced
Widowed
Partnered
Separated
I do not wish to answer
What language do you speak at home? Select all that apply:
Highest grade or college level completed?
Grade School
High School
College - Associates
College - Bachelor
College - Masters
College - PHD
Other
In general, how do you rate your health?
Excellent
Good
Fair
Poor
Don't Know
Please tell us your age:
Under 59
60-64
65-69
70-74
75-79
80-84
85+
How often do you feel lonely or isolated?
Often
Sometimes
Rarely
Never
Do you have internet access at home?
Yes
No
Do you feel prepared for emergencies (storms, evacuations, power outages, etc.)?
Yes
No
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