Attachment 1: Questions to be cognitively tested
Form Approved
OMB No. 0920-0222
Exp. Date: 01/31/2026
Notice - CDC estimates the average public reporting burden for this collection of information as 60 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).
Assurance of Confidentiality: We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act (44 U.S.C. 3561-3583). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.
Proposed Questions:
Q1. During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?
Yes
No
Caregiving recipient died in past 30 days
Don’t know
Refused
Q2. Do you consider yourself a caregiver for a friend or family member?
Yes
No [end]
Caregiving recipient died in past 30 days [end]
Don’t know [end]
Refused [end]
Q3. How many people with a health care problem or disability did you provide care for in the past 30 days?
1
2
3
4 or more
Q4. For the next few questions, please only think about the person you care for the most. What is their relationship to you? For example, is this person your mother or daughter or father or son?
Parent, stepparent, or parent-in-law
Grandparent, step grandparent or grandparent-in-law
Spouse or partner
Child or stepchild
Grandchild or step grandchild
Sibling, stepsibling, or sibling-in-law
Other relative
Friend or non-relative
Don’t know
Refused
Q5. How old is that person?
Under 18 years of age
Aged 18-44 years
Aged 45-64 years
Aged 65 years or older
Don’t know
Refused
Q6. What is the main health problem or disability that the person you care for has?
Alzheimer’s disease, dementia or other cognitive impairment [skip to question 8]
Heart disease, hypertension, or stroke
Cancer
Diabetes
Injuries including broken bones or traumatic brain injury
Mental illness such as depression, anxiety, or schizophrenia
Developmental disorders such as autism, Down syndrome, or spina bifida
Respiratory conditions such as asthma, emphysema, or chronic obstructive pulmonary disease
Arthritis/rheumatism
Hearing or vision loss
Movement disorders such as Parkinson’s, spinal cord injury, or multiple sclerosis
Old age, infirmity, or frailty
Other
Q7. Does the person you care for also have Alzheimer’s disease, dementia or other cognitive impairment?
Yes
No
Don’t know
Refused
Q8. In the past 30 days, did you provide care for this person by helping with nursing or medical tasks such as injections, wound care, or tube feedings?
Yes
No
Don’t know
Refused
Q9. In the past 30 days, did you provide care for this person by managing personal care such as bathing, getting to the bathroom, or helping to eat?
Yes
No
Don’t know
Refused
Q10. In the past 30 days, did you provide care for this person by managing household tasks such as help with transportation, shopping, or managing money?
Yes
No
Don’t know
Refused
Q11. In the past 30 days, did you provide care for this person by coordinating their care such as scheduling appointments, dealing with insurance, or filling out paperwork?
Yes
No
Don’t know
Refused
Q12. In the past 30 days, did you provide care for this person through mental health support, emotional support, or companionship?
Yes
No
Don’t know
Refused
Q13. In an average week, how many hours do you provide regular care or assistance? Would you say…
Up to 19 hours per week
20 to 39 hours per week
40 hours or more per week
Q14. How long have you provided regular care to this person? Would you say…
Less than 30 days
1 month to less than 2 years
2 years to less than 5 years
More than 5 years
Q15. Does this person receive any additional unpaid or paid care besides routine medical care?
Yes
No
Don’t know
Refused
Q16. Do you get paid to provide care for this person?
Yes
No [go to question 17]
Don’t know [go to question 17]
Refused [go to question 17]
Q17. What is the main source from which you are paid?
I am paid by the person I care for or their family directly.
I am paid through a state or community agency like an Area Agency on Aging
I am paid through a health care system like the VA
I am paid through an insurance provider like Medicaid or a private insurance plan
Other (can we get text responses from cognitive interviews to help inform categories?)
Don’t know
Refused
Q18. Various services or supports may be available to assist you in providing care. Which of the following services or supports do you currently use that is most important caring for this person?
Out of home services for the care recipient
In home services for the care recipient
Caregiver support groups
Food and nutrition service for care recipient
Transportation services for care recipient
Financial planning for care recipient
Caregiving/caregiver skills-based training (e.g., The Savvy Caregiver)
Other
I don’t use any services
Don’t know
Refused
Q19. Do you have friends or family that help you out?
Yes
No
Don’t know
Refused
Q20. Has being a caregiver created financial difficulty for you?
Yes
No
Don’t know
Refused
Q21. Has being a caregiver provided you personal fulfillment, purpose, or satisfaction?
Yes
No
Don’t know
Refused
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Massey, Meredith (CDC/DDPHSS/NCHS/DRM) |
File Modified | 0000-00-00 |
File Created | 2025-05-19 |