03 Caregiver Survey

OMB Control Number 3045-XXXX, Expiration XX/XX/20XX

AmeriCorps Seniors Evaluation:  

Respite Caregiver Survey  

Senior Companion Program  

 

Caregiver Experience  

 

1. Approximately, what year did a Senior Companion volunteer begin to provide you services? 

 

 Year ________   GO TO Q4 

 

( ) I don’t remember  GO TO Q2 

 

 2. If you cannot recall the year, how many years have you had a Senior Companion from your Senior Companion Program? 

 

_______ years GO TO Q4 

 

( ) I don’t remember GO TO Q3 

 

3. If you cannot recall number of years, would you say you have been receiving services from the [SCP program] for: 

 

a. Less than 1 year 

b. 1 to 3 years 

c. 4 to 5 years 

d. 6 to 9 years 

e. 10 years or More 

 

We would like to ask about your caregiver respite services you received from  your Senior Companion Program.  

 

4. Over the past month, about how many total hours of services did the Senior Companion volunteer provide? Please write the number of hours in the space below.   

 

1. I received about ______ total service hours the past month 

2. Don’t remember 

 

5. Is this typical of the number of hours you receive each month?   

1. Yes   

2. No   

3. Not sure   

4. Don’t remember  

 

6. Overall, how satisfied are you with the Senior Companion Program respite services you are receiving?    

 

1. Very dissatisfied 

2. Somewhat dissatisfied 

3. Somewhat satisfied 

4. Very satisfied 

 

7. How likely are you to recommend your Senior Companion Program respite services to a friend?  

 

1. Not at all likely 

2. Not likely 

3. Very likely 

4. Extremely likely 

 

 

Health and Psychosocial Outcomes 

 

8. How would you rate your current physical health?   

 

1. Fair 

2. Good 

3. Very good 

4. Excellent 

 

9. How would you rate your current mental health (i.e., emotional and psychological wellbeing)? 

 

1. Poor 

2. Fair 

3. Good 

4. Very good 

5. Excellent 

 

The next questions are about how you feel about different aspects of your outlook on life, your life, and about your health. 

This information can inform the program on how to better support you and other caregivers like you who are getting services.  

(Mark (X) in one box for each line.) 

 

10. The next statements are how you feel about your ability to complete a task.  

 

(Mark (X) one box for each line.)    

	Strongly Disagree	Disagree	Agree	Strongly Agree	Don’t Know	Prefer Not to Answer
I can do just about anything I really set my mind to.	(   )	(   )	(   )	(   )	(   )	(   )
I can do the things that I want to do.	(   )	(   )	(   )	(   )	(   )	(   )

 

11. The next statements are about your life and situation right now…  

 

(Mark (X) one box for each line.)   

 

	Very Dissatisfied	Somewhat Dissatisfied	Somewhat Satisfied	Very Satisfied	Don’t Know	Prefer Not to Answer
How satisfied are you with the city or town you live in?	(   )	(   )	(   )	(   )	(   )	(   )
How satisfied are you with your daily life and leisure activities?	(   )	(   )	(   )	(   )	(   )	(   )
How satisfied are you with your family life?	(   )	(   )	(   )	(   )	(   )	(   )
How satisfied are you with your present financial situation?	(   )	(   )	(   )	(   )	(   )	(   )
How satisfied are you with your health?	(   )	(   )	(   )	(   )	(   )	(   )
How satisfied are you with your life-as-a-whole these days?	(   )	(   )	(   )	(   )	(   )	(   )

 

 

12. The next questions reflect people’s thoughts and feelings. Please answer how you feel about each question.  

 

(Mark (X) one box for each line.)   

 

	Often	Some of the time	Hardly Ever or Never	Don’t Know	Prefer not to Answer
How much of the time do you feel that you are alone?	(   )	(   )	(   )	(   )	(   )
How much of the time do you feel that you lack companionship?	(   )	(   )	(   )	(   )	(   )
How much of the time do you feel left out?	(   )	(   )	(   )	(   )	(   )
How much of the time do you feel isolated from others?	(   )	(   )	(   )	(   )	(   )
How much of the time do you feel that there are people you feel close to?	(   )	(   )	(   )	(   )	(   )
How much of the time do you feel that there are people you can turn to?	(   )	(   )	(   )	(   )	(   )

 

 Service Delivery 

 

13. How satisfied are you with the Senior Companion volunteer? 

   

1. Very dissatisfied 

2. Somewhat dissatisfied 

3. Somewhat satisfied 

4. Very satisfied 

 

14. Where are you currently receiving Senior Companion services?  

 

1. My home  

2. Family/friend home or house 

3. Adult daycare center 

4. Senior center 

5. Hospital 

6. Health/medical center 

7. Library 

8. Social Service program 

9. Veterans facilities 

10. Other non-profit or faith-based organization 

11. Virtual – Telephone / Computer 

12. Other location – Please specify: _____________________________________ 

 

Caregiver Satisfaction 

 

The next few questions ask about your satisfaction with your Senior Companion Program service experience. 

 

15. How helpful have the following aspects of the program been?  

 

(Mark (X) one box for each line.)  

 

	Not at all helpful	A little helpful	Very helpful	Extremely helpful
My Senior Companion volunteer’s skills / abilities	( )	( )	( )	( )
Responsiveness from people in the Senior Companion program	( )	( )	( )	( )
The program’s flexibility when requesting services	( )	( )	( )	( )

 

 

16. For each of the next few statements, how satisfied are you about…  

 

(Mark (X) one box for each line.) 

 

	Very dissatisfied	Dissatisfied	Satisfied	Very satisfied
Getting help with respite services when I need it	( )	( )	( )	( )
My relationship with Senior Companion volunteer	( )	( )	( )	( )
The flow of communication from Senior Companion program staff	( )	( )	( )	( )
The support I receive from people in the program	( )	( )	( )	( )

16. What do you most appreciate about your Senior Companion Program caregiver respite services?   

1. Please write in: _________________________________________  

_________________________________________ 

2. Don’t know 

3. Prefer not to answer 

 

 

Covid-19  

March 11, 2020 marks the official date that Covid-19 was declared a pandemic. This announcement marks the start of many restrictions including mask mandates in most cities and states, school closure, working from home and remotely, and suspension of air travel both domestically and internationally. These restrictions would last at least a year or more. This section will ask about your volunteer experience at the start and during the declaration of Covid-19 pandemic. 

 

18. Were you receiving Senior Companion services in March 2020? 

 

1. Yes    

2. No [SKIP TO – DEMOGRAPHICS SECTION]  

3. Don’t remember [SKIP TO – DEMOGRAPHICS SECTION]  

 

19. During the Covid-19 pandemic, did you continue to receive senior companion services? 

 

1. Yes  

2. No, my station closed I did not receive services [SKIP TO – DEMOGRAPHICS SECTION]  

3. No, I was concerned about the pandemic, I stopped the senior companion services [SKIP TO – DEMOGRAPHICS SECTION]  

4. Don’t remember [SKIP TO – DEMOGRAPHICS SECTION]  

 

20. After March 2020, during the Covid pandemic, how many hours per month did you typically receive services from your Senior Companion Program? 

 

1. About _______________hour per month 

2. Don’t remember 

 

 

21. After March 2020 during the Covid pandemic), where did the Senior Companion volunteer provide services?  

 

1. I did not have a Senior Companion volunteer after March 2020 

2. My home or house 

3. Family/friend home or house 

4. Adult daycare center 

5. Senior center 

6. Hospital 

7. Health/medical center 

8. Library 

9. Social Service program 

10. Veterans facilities 

11. Other non-profit or faith-based organization 

12. Other location – Please specify: ______________________________________ 

 

22. How satisfied were you (as a whole) with the adjustments your station made in response to COVID-19? 

 

1. Very dissatisfied 

2. Dissatisfied 

3. Satisfied 

4. Very satisfied 

 

 

23. Which of the following measures did your station implement in response to Covid-19 (at any point during the pandemic)?  

 

[SELECT ALL THAT APPLY]  

 

1. Suspension of in-person services 

2. Required masking/face covering 

3. Required Covid-19 testing 

4. Required Covid-19 vaccination 

5. Fever screening or other symptom screening 

6. Installing physical barriers to reduce close contact 

7. Reduction in maximum occupancy (i.e. the number of people allowed inside) 

8. Reduction of in-person volunteering hours (when in-person services were allowed) 

9. Rigid scheduling of in-person services 

10. Socially distant services (volunteer is physically present but no face-to-face interaction with clients, e.g. delivering food) 

11. Remote volunteer services (volunteer is not physically present and not using technology, e.g. sending pen pal letters) 

12. Virtual volunteer services (volunteer provides services using technology, e.g. a phone or computer) 

13. Nothing changed – continued doing in-person services (my volunteer was physically present) 

 

24. Have you had or do you now have COVID-19?   

 

1. YES, I was tested 

2. PROBABLY YES (I THINK SO), I was not tested 

3. NO [SKIP TO – DEMOGRAPHICS SECTION] 

4. PROBABLY NO (I DON’T THINK SO), I have not been tested [SKIP TO – DEMOGRAPHICS SECTION] 

5. NOT SURE [SKIP TO – DEMOGRAPHICS SECTION] 

6. DON’T KNOW [SKIP TO – DEMOGRAPHICS SECTION] 

7. REFUSE [SKIP TO – DEMOGRAPHICS SECTION] 

 

25. Are you experiencing any long-term health effects from COVID-19 infection? 

 

1. Yes 

2. No 

3. Don’t Know 

26. To what extent do you agree or disagree that COVID-19 has affected the types of respite services you receive from your Senior Companion volunteer? 

 

1. Strongly disagree 

2. Disagree 

3. Agree 

4. Strongly agree 

 

27. In your own words, could you share what your senior companion service experiences were due to Covid-19? 

_______________________________________________________ 

_______________________________________________________ 

_______________________________________________________ 

  

Demographics 

Please answer the following questions to help us understand about you and AmeriCorps Seniors volunteers generally. 

 

28. When were you born?    

Please enter two digits in month and four digits in year (e.g., 01 for January) 

 

Month: [    ][    ] 

 

Year: [    ][    ][    ][    ] 

 

29. Do you consider yourself of Hispanic or Latino origin?   

1. Yes 

2. No 

 

30. What race(s) do you identify most closely with? Select all that apply.  

 

1. American Indian or Alaska Native 

2. Asian 

3. Black or African American 

4. Native Hawaiian or Other Pacific Islander 

5. White 

 

31. Are you: [SELECT ALL THAT APPLY]   

 

1. Male 

2. Female 

3. I use a different term. Please write in: ____________________ 

4. Prefer not to answer 

 

32. What is your current marital status?  

 

1. Never married 

2. Married / Partnered 

3. Divorced / Separated 

4. Widowed 

5. Other – Please describe: ______________________________ 

6. Prefer not to answer 

 

33. What is the highest grade of school you completed?   

 

1. No formal education 

2. Grades 1-11 

3. Grade 12 (High School Diploma or GED) 

4. Some College 

5. Associate’s Degree 

6. Bachelor’s Degree/College Graduate 

7. Some graduate school 

8. Completed a graduate/professional degree 

9. Other – Please describe: __________________________ 

10. I don’t know 

11. I prefer not to answer 

 

34. Are you currently employed? 

 

1. Yes, full time 

2. Yes, part time 

3. No, retired 

4. No, currently unemployed/seeking employment 

5. No, I have a disability 

6. Other, please specify: _____________________ 

 

35. Have you served in the military?   

 

1. Yes 

2. No 

 

36. Including yourself, how many people live in your household? Please write the number in the space below.   

 

1. ________________________________ 

 

2. Prefer not to answer 

 

37. How many children do you have? Please write the number of children in the space below.   

 

1. Number of children: ________________________________ 

2. No children [SKIP to Question 39] 

3. Prefer not to answer [SKIP to Question 39] 

 

38. Do any of your children live within 10 miles of you?  

 

1. Yes 

2. No 

3. Prefer not to answer 

 

39. Which category best describes your total annual household income?   

 

1. Less than or equal to $20,000 [SKIP to Question 41] 

2. Greater than $20,000 

3. Don’t know [SKIP to Question 41] 

4. Prefer not to answer [SKIP to Question 41] 

 

40. IF MORE THAN $20,000: Would you say it is......   

 

1. Greater than $20,000 but no more than $30,000 

2. Greater than $30,000 but no more than $40,000 

3. More than $40,000 

4. Don’t know 

5. Prefer not to answer 

 

The study would like to ask some questions about the family member or friend you are caring for. 

 

41. What is your relationship to the person you are caring for? 

 

1. Wife / Husband / Partner 

2. Mother / Father 

3. Mother-in-law / Father-in-law 

4. Grandchild 

5. Brother / Sister 

6. Brother-in-law / Sister-in-law 

7. Son / Daughter 

8. Friend 

9. Other, please specify: _________________________ 

10. Don’t Know 

11. Prefer not to answer 

  

42. How long have you been caring for your family member or friend? 

 

1. Less than 6 months 

2. 6 to 12 months 

3. 13 to 24 months 

4. More than 24 months but less than 5 years 

5. 5 years or more 

6. Don’t Remember 

7. Don’t Know 

8. Prefer not to answer 

 

43. Do you live in the same household as the family member or friend you are caring for? 

 

1. Yes 

2. No 

3. Don’t Know 

4. Prefer not to answer 

[End of Survey] 

Thank you again for taking the time to participate in the AmeriCorps Seniors Companion caregiver survey. 

 
The JBS evaluation team will only use your responses for research and statistical purposes.

Just to make sure that you receive your gift card, could you provide your contact information.

First Name: _________________________________________________

Last Name: _________________________________________________

Street Address: ___________________________________________________

__________________________________________________________

City: ____________________ State: ___________ Zip: ____________

Phone: _______________________________________________________

E-mail: _______________________________________________________

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. A Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. The public reporting burden for this voluntary collection of information is estimated to at 30 minutes per response, including time reviewing and completing the collection of information. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to AmeriCorps Information Collection Clearance Officer, 250 E Street, SW, Washington, DC 20024. Note: Please do not return the completed survey to this address, however.