Caregiver Eligibility Screener

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Earn a $100 gift card for talking about your experience as a Caregiver for Medicare enrollees’

A Centers for Medicare & Medicaid Services (CMS) team that connects health information to apps is conducting research. They are interested in better understanding how people use their health information so that they can better support their needs. 

Taking the survey below will determine if you qualify for participating in this project. If you qualify and participate in the session, you will receive a $100 gift card.

This session will last one hour, and will take place on Microsoft Teams.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1382. 
What is the goal?
This information collection is for understanding Caregivers needs and challenges as it relates to technology, access, data sharing and privacy and making recommendations to CMS for how to better serve Caregiver needs. 

How long will it take?
The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. 

You can leave for any reason and your privacy is important.
This information collection is voluntary, and confidential. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.


* Indicates required question

    1. In the past 6 months, which of the following have you done regularly for the same person — meaning at least 15 hours per week? (Select all that apply) *
    • Prepared meals or handled grocery shopping for another person
    • Managed finances or paid bills on behalf of someone else
    • Driven or arranged transportation for someone to get to appointments or errands
    • Helped someone with personal care such as bathing, dressing, or grooming
    • Managed or organized medications for another person 
    • Provided emotional support or companionship to someone who relies on you
    • Assisted someone in understanding or managing their health insurance or medical bills 
    • Coordinated medical appointments or communicated with healthcare providers on someone's behalf
    • Provided supervision or safety monitoring for someone who cannot be left alone
    • Helped with housekeeping, home maintenance, or repairs for another person [DISQUALIFY IF SELECTED ALONE]
    • None of the above [DISQUALIFY]

    2. Thinking about this other person, which best describes them the most? (Select one) *
    • A child or teenager under 18 [DISQUALIFY]
    • A young adult (18–29) [DISQUALIFY]
    • A middle-aged adult (30–64) [DISQUALIFY]
    • An older adult (65+)
    • I'm not sure
    • I don't regularly assist anyone [DISQUALIFY]

    3. Which of the following types of health insurance or coverage does the person currently have? (Select all that apply) *
    • Through an employer  [DISQUALIFY]
    • Through spouse's employer  [DISQUALIFY]
    • Purchased independently or through a state marketplace [DISQUALIFY]
    • Medicaid (state-funded coverage, often for lower-income individuals) [DISQUALIFY IF SELECTED ALONE]
    • Medicare (federal coverage, typically for people 65+ or with certain disabilities) 
    • A Medicare Advantage plan (a private plan that replaces traditional Medicare) [DISQUALIFY IF SELECTED ALONE]
    • VA or military health benefits [DISQUALIFY IF SELECTED ALONE]
    • No health insurance [DISQUALIFY]
    • I'm not sure what coverage they have 

    4. How long have you been helping this person for at least 15 hours per week?(Select one) *
    • Less than 1 month [DISQUALIFY]
    • 1-2 months [DISQUALIFY]
    • 3-6 months
    • 7-11 months
    • 1-3 yrs
    • 3+ years

    5. Which of the following best describes your relationship to this person? (Select all that apply) *
    • A spouse, partner, or significant other providing care or support
    • A parent, in-law, or grandparent providing care or support
    • A sibling or other relative providing care or support
    • A friend, neighbor, or colleague helping informally
    • Hired directly and privately by the person or their family
    • Employed by a home care or staffing agency
    • Working in a coordination, programming, or support role at a community-based or senior services organization
    • Other: _____

    6. Without sharing a diagnosis, how would you describe the primary reason this person needs assistance? (Select all that apply) *
    • Challenges related to memory, thinking, or cognition
    • A serious or chronic physical illness
    • Recovery from a surgery, injury, or acute health event
    • Difficulty with mobility or physical functioning
    • A mental health or behavioral condition
    • Age-related changes in energy, strength, or independence
    • Multiple overlapping health or functional challenges
    • Other: _____

    7. Including this person, how many people do you regularly assist? (Select one) *
    • Just 1
    • 2–3
    • 4 or more

    8. On a scale of 1 to 5, how would you rate your comfort using everyday technology? (1 = Not comfortable at all, 5 = Very comfortable) (e.g., logging into online portals, downloading apps) *

    9. What is your sex? (Select one) *
    • Woman
    • Man
    • Prefer not to say

    10. What is your age? (select one) *
    • 18–34
    • 35–44
    • 45–54
    • 55–64
    • 65–74
    • 75 or older
    • Prefer not to say
    • Other______


    11. What is your preferred name? *
What would you like to be called if you're selected to talk to the team?

______________________________

    12. Email * __________________________

    13. Are you interested in participating in this type of session in the future? *
If you select Yes, we may contact you about similar opportunities in the future. That is the only communication you will receive from this team. You can change this response at any time by emailing [email protected].

If you select No, we will only contact you about this opportunity.

We will never sell or share your email with anyone, regardless of your choice.

Mark only one oval.
        ◦ Yes
        ◦ No
        ◦ Other: ______________________