POST SURVEY Date __________________
1. Name a caregiver you know currently.
2. Two community resources for caregivers are:
a. Area Agency on Aging of Western Michigan
b. HHS, Inc.
c. Senior Neighbors, Inc.
d. Grand Rapids Community College
3. The effects of caregiving on the caregiver can be:
a. Social
b. Emotional
c. Physical
d. Spiritual
e. All of the above
4. I could do __________________________________________ to raise caregiver awareness in my workplace, church, etc.
5. Two statistics you believe to be true about caregiving that is provided in the United States are:
a. Nearly 1 in 4 households in America are involved in caregiving
b. 75% of all caregivers for older people are women
c. In Kent County, 37% of residents surveyed are providing care to elderly relatives or friends
This Fact Sheet is provided as a public service of the Caregiver Resource Network. The Caregiver Resource Network is a collaboration of Kent County organizations dedicated to providing for the needs and welfare of family and professional caregivers within the community. Funded by the Area Agency on Aging of Western Michigan with Older American’s Act Title IIIE, Family Caregiver Support Funds. Revised 2/13/03
www.CaregiverResource.net
or call 616-456-5664
I am currently a caregiver, and I care for my (please circle one):
Spouse Sibling
Parent Friend
Child Other
Age _______________
Caregiver Age _______ Caregiver Gender: M____ F____
Caregiver Ethnic/Racial Background:
______African - American
______Asian
______Hispanic
______Native American
______White
______Other
Caregiver Annual Household Income:
______$0 - $10,000
______$10,000 - $20,000
______$20,000 - $30,000
______$30,000 - $40,000
______$40,000 - $50,000
______$50,000 - $75,000
______$75,000 - $100,000
______$100,000 or above
______I would like a phone call to find out about caregiver resources.
______My club or organization would like a presentation. Please call me.
Name (optional)_______________________________
Phone: _____________________________
(If requesting a call, please make sure your name appears above).