Attachment B-8: Caregiver Services | ADMINISTRATION-5600-MANUAL

Item #	HCBS Caregiver Services Survey Questions	Answer Options
As a result of the Caregiver Services, do you…	Yes No
1.	Have more time for personal activities? (For example: church, shopping for yourself, walking, reading, exercising, movies, talking with friends)
2.	Have more time to do daily activities or chores? (For example: house cleaning, yard work, shopping for groceries, running errands, picking up medications)
3.	Feel less stress?
4.	Have a clearer understanding of how to get the services you and your Care Receiver need?
5.	Know more about your Care Receiver’s condition or illness?
6.	Feel more confident in providing care to your Care Receiver?
7.	Have the Caregiver Services helped you to provide care for a longer period of time than would have been possible without these services?
8.	Would you say Caregiver Services have helped you be a better caregiver?
9.	Have the Caregiver Services helped your Care Receiver to continue to be able to live at home?
10.	Overall, how satisfied are you with the Caregiver Services you receive?	Satisfied Somewhat Satisfied Dissatisfied
11.	Who would you contact first if you had a problem with the Caregiver Services?	The Aide’s or Worker’s Supervisor Case Manager’s Supervisor or Agency Area Agency on Aging Division of Aging Services Do Not Know Others:
12.	In your opinion, how could we improve Caregiver Services for you? Please mark all that apply.	Need the same aides/workers each time. Need better trained aides/workers. I would like to choose my aides/workers. Need the aides/workers to do more for me. Need the aides/workers to arrive on time as scheduled.
		Need the aides/workers for more hours and/or more days. Need the aides/workers to do things the way I want them to be done. Need aides/workers to stay the full amount of time scheduled. Need more information on my Care Receiver’s illness or how to provide better care.
13.	Please tell us any other suggestions you have to improve the quality of Personal Care Services you receive.	Comments:

Item #

HCBS Caregiver Services Survey Questions

Answer Options

As a result of the Caregiver Services, do you…

Have more time for personal activities? (For example: church, shopping for yourself, walking, reading, exercising, movies, talking with friends)

Have more time to do daily activities or chores? (For example: house cleaning, yard work, shopping for groceries, running errands, picking up medications)

Feel less stress?

Have a clearer understanding of how to get the services you and your Care Receiver need?

Know more about your Care Receiver’s condition or illness?

Feel more confident in providing care to your Care Receiver?

Have the Caregiver Services helped you to provide care for a longer period of time than would have been possible without these services?

Would you say Caregiver Services have helped you be a better caregiver?

Have the Caregiver Services helped your Care Receiver to continue to be able to live at home?

10.

Overall, how satisfied are you with the Caregiver Services you receive?

Satisfied
Somewhat Satisfied
Dissatisfied

11.

Who would you contact first if you had a problem with the Caregiver Services?

The Aide’s or Worker’s Supervisor
Case Manager’s Supervisor or Agency
Area Agency on Aging
Division of Aging Services
Do Not Know
Others:

12.

In your opinion, how could we improve Caregiver Services for you? Please mark all that apply.

Need the same aides/workers each time.
Need better trained aides/workers.
I would like to choose my aides/workers.
Need the aides/workers to do more for me.
Need the aides/workers to arrive on time as scheduled.

Need the aides/workers for more hours and/or more days.
Need the aides/workers to do things the way I want them to be done.
Need aides/workers to stay the full amount of time scheduled.
Need more information on my Care Receiver’s illness or how to provide better care.

13.

Please tell us any other suggestions you have to improve the quality of Personal Care Services you receive.

Comments:

If the survey is to be administered by mail, please do not ask the consumer to identify him/herself, unless he or she wishes to be contacted for follow-up. Add lines at the end of the survey for the consumer to indicate voluntarily a desire for a contact and to provide his or her name and telephone contact information.