10-10119 Caregiver Feedback Form

VA CAREGIVER SUPPORT PROGRAM SELF-CARE COURSE FORM OMB 2900-0770

Estimated Burden 10 min.

EXP Date: XX/XX/XXXX

CAREGIVER FEEDBACK

VA CAREGIVER SUPPORT PROGRAM

SELF-CARE COURSE

O MB 2900-0770

Estimated Burden 10 min.

EXP DATE: XX/XX/XXXX

This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this form will average 10 minutes. This includes the time it will take to read instructions, gather facts and fill out the form. The Participant Feedback Form will be used to gauge customer perceptions of VA Caregiver training services and program satisfaction. The results of this feedback will lead to improvement in the quality of service delivery by helping to shape the direction and focus of specific programs or services. Completion of this form is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

VA Form: 10-10119

Please select the course name

M anaging Stress

P roblem Solving and Effective Communication

T aking Care of Yourself

Utilizing Technology

Course Date:

Course Location:

W hat is your relationship to the care recipient:
Spouse/partner

Son/Daughter/Stepchild

Parent

Other relative: _____________

Friend

2. What is your gender? start

□ Female

□ Male

3. How old are you?

□ 18-19 years old

□ 20-29 years old

□ 30-39 years old

□ 40-49 years old

□ 50-59 years old

□ 60-69 years old

□ 70-79 years old

□ 80+ years old

4. How long have you been a Caregiver?

□ Less than 1 year

□ 1 to 2 years

□ 3 to 5 years

□ 6 to 10 years

□ More than 10 years

Please select the answer that best describes your level of agreement with the following statements:

5. I would recommend this course to other Caregivers

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

5. The course content met my needs

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

5. I learned new information in this course

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

5. The Instructors were knowledgeable and presented the information in a way I could understand

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

5. I plan to use the information from this course in my role as a Caregiver

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

5. This course increased my knowledge and skill as a Caregiver

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

5. This course increased my knowledge and ability to take care of my physical and/or emotional health

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

5. What information/topic from the course was most useful to you?

5. What information/topic was least useful to you?

5. Additional comments or suggestions?

VA Form 10-10119
July 2014