Statewide Respite Survey

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Thank you for taking your time as a caregiver to respond to this survey and help us better understand what type of respite services you need in order to keep your family's loved one in their home as long as possible.

Are you a caregiver? A family caregiver can be someone caring for a spouse, child, parent, or other extended family or even a friend or neighbor. Do you provide help with any of the following?

Transportation to medical appointments? Organizing medications, advocating with health care providers, providing help with dressing, bathing, showering, grocery shopping, and preparing meals?

If you answered yes to any of the above questions, you are a caregiver and we would appreciate hearing from you. The results are confidential and information will be shared to better understand and support caregivers with services. We would appreciate your response at your earliest convenience.

Thank you in advance for your time.

Caregiver Age *

Caregiver Gender *

Caregiver Race *

Caregiver Zip Code *

Caregiver Primary Language *

The county in which you live *

How many hours do you spend caregiving each day? *

How many days per week do you provide caregiving support? *

For whom are you providing care (ex: child, spouse, parents, family member that is not a child or spouse) *

What is your current income? *

Under $25,000 per year

Under $40,000 per year

Under $50,000 per year

Under $60,000 per year

Under $80,000 per year

Under $100,000 per year

$101,000 or more

Caregiver is currently caring for a loved one who (select applicable age) *

Is under 18 years of age

Is between 18 and 30 years of age

Is between 31 and 50 years of age

Is between 51 and 60 years of age

Is over 61 years of age

The loved one I am caring for has (please select all that apply) *

Physical disability

Chronic illness

Intellectual / developmental disability

Mental / emotional illness

Other:

Required

The most difficult part of being a caregiver is (select all that apply): *

Meeting personal needs

Personal finances

Balancing family, work and caregiving duties

Spending time with other loved ones

Completing daily chores/ tasks (cleaning, grocery shopping, etc. personal chores specific to caring for the individual's needs)

Managing personal health/ mental health

Knowing what other resources are available

Other:

Required

In the past year, how has your employment been impacted due to the time needed to care for your loved one? (Please select all that apply) *

I needed to go down to part-time work from working full-time

I needed to quit my job and we lost income due to the caregiving needs required

My employer has been working with me on time off and I have been able to keep my job

I have exhausted my benefit time. When I take time off to fulfill caregiving responsibilities it is often without pay or soon will be without pay

My employment has not been impacted

Other:

Required

I currently receive support through: *

IDHS DDD, DCFS, IDOA, IDORS, please list if it's another agency

I do not currently receive any respite-funded services/ support

I pay out of pocket for respite support

My insurance company provides me with respite support (if so, please list)

Other:

In the past year I have received respite services (select al that apply) *

Weekly support

Monthly support

Sporadically (please list hours below)

I have applied for respite services but have not received respite services

I don't know how or where to apply, I did not know that respite is an option in my area

I did not apply for respite

Other:

Required

If you have applied but not received services, what was the reason?

No staff

Not sure of what I need

I do not qualify due to my income

I am not looking for outside respite help

Clear selection

If you have decided not to apply for respite, why?

If I had a choice, I would prefer to have respite (please select one): *

In my home

Out of my home (in a supervised day or group program)

In another program of my choice

I would prefer that my loved one was in a residential setting

Other:

If I had a choice, please select one: *

I would prefer to pick my respite staff including the staff being a family member living outside or inside the same

I would prefer to have an agency train and provide staff since I do not know or have anyone that can provide respite to my family

I would prefer the agency to be the employer and handle pay, training, tax and liability insurance for my respite staff whether that are a family member or agency-provided staff

I would prefer to receive a respite stipend/ voucher to pay for the type of respite services that work best for our family and work out the tax and insurance on our own

I would prefer to have a voucher or stipend to pay for respite support each year (if so, please answer the following question)

The cost of the voucher to best meet my family's needs (please select one): *

If other, please provide the amount needed for respite support

$500/ per year

$1,000/ per year

Other:

I would be able to keep our loved one at home, if we received respite hours on a monthly basis up to (select one): *

10 hours monthly

20 hours monthly

30 hours monthly

More than 30 hours a month

We would like to take a week of vacation once a year

Other:

Positive impacts to caregiving are (please list as many answers as you want) *

Negative impacts to caregiving include (please list as many answers as you want) *

Impacts on employment include (please list as many answers as you want) *

Impacts on friends, family and health include (please list as many answers as you want) *

What are some additional services that you would like to have (example more flexibility, more hours, choice of respite services - in-home, voucher, residential) *

Do you know what services are available for caregivers in your county? *

Is there anything that you would like us to know about caregiving for a loved one? *

Would you like the Illinois Respite Coalition to follow up with you regarding this survey and your needs? If yes, please list your name, phone number and email below. *

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