ca002 (who caregiving for)
Who is the family member or close friend you are caregiving for?
If you provide care to more than one person, please indicate the person who requires the most time and energy from you as a caregiver.
1 Spouse/ partner
2 Parent
3 Son or daughter
4 Son or daughter-in-law
5 Grandparent
6 Grandchild
7 Sibling
8 Other relative
9 Friend/ companion, roommate
10 I am employed as a paid caregiver
if ca002 != 10 then
ca003 (paid to caregive)
Are you paid to provide care to that family member or close friend?
1 (YES) Yes
2 (NO) No
End of if
Group of questions presented on the same screen
ca004 (which conditionds or disabilities)
Which of the following conditions or disabilities, if any, apply to the person you are helping to care for? Please check all that apply, or write in an answer if it is not in the list below.
1 Alzheimer's disease, other dementia or cognitive impairment
2 Cancer
3 Stroke
4 Intellectual or developmental disability
5 Physical disability or injury
6 Mental health or psychiatric disability
7 Diabetes
8 Heart disease
9 Other chronic illness
10 Vision impairment, blindness
11 Other age-related impairments
12 Other (please write in):
13 None
ca004_other (other which conditionds or disabilities)
STRING
End of group of questions
Group of questions presented on the same screen
ca005_intro
Does that family member or close friend need help with any of the following activities?
Subgroup of questions
ca005a (Getting across a room)
Getting across a room
1 (YES) Yes
2 (NO) No
ca005b (Bathing)
Bathing
1 (YES) Yes
2 (NO) No
ca005c (Eating)
Eating
1 (YES) Yes
2 (NO) No
ca005d ( Getting in and out of bed)
Getting in and out of bed
1 (YES) Yes
2 (NO) No
ca005e (Using the toilet)
Using the toilet
1 (YES) Yes
2 (NO) No
ca005f (Preparing a hot meal)
Preparing a hot meal
1 (YES) Yes
2 (NO) No
ca005g (Shopping for grocery and other necessities)
Shopping for grocery and other necessities
1 (YES) Yes
2 (NO) No
ca005h (Making phone calls)
Making phone calls
1 (YES) Yes
2 (NO) No
ca005i (Taking medication)
Taking medication
1 (YES) Yes
2 (NO) No
ca005j (Paying bills and keep tracking of expenses)
Paying bills and keep tracking of expenses
1 (YES) Yes
2 (NO) No
ca005k (Managing money)
Managing money
1 (YES) Yes
2 (NO) No
End of subgroup of questions
End of group of questions
if ca005a = 1 OR ca005b = 1 OR ca005c = 1 OR ca005d = 1 OR ca005e = 1 OR ca005f = 1 OR ca005g = 1 OR ca005h = 1 OR ca005i = 1 OR ca005j = 1 OR ca005k = 1 then
if ca005a = 1 then
End of if
if ca005b = 1 then
End of if
if ca005c = 1 then
End of if
if ca005d = 1 then
End of if
if ca005e = 1 then
End of if
if ca005f = 1 then
End of if
if ca005g = 1 then
End of if
if ca005h = 1 then
End of if
if ca005i = 1 then
End of if
if ca005j = 1 then
End of if
if ca005k = 1 then
End of if
ca006 (which activies assist with)
Which of these activities do you assist that family member or close friend with? Please check all that apply.
1 Getting across a room
2 Bathing
3 Eating
4 Getting in and out of bed
5 Using the toilet
6 Preparing a hot meal
7 Shopping for grocery and other necessities
8 Making phone calls
9 Taking medication
10 Paying bills and keep tracking of expenses
11 Managing money
12 None of the above
End of if
ca007 (where living person giving care for)
Where does the family member or close friend for whom you are a caregiver live?
1 With me
2 With another family member
3 By themselves
4 In a nursing home
5 Other
ca008 (who is caregiving)
Are you the only person assisting that family member or close friend or is somebody else providing care?
1 I am the only caregiver
2 I do most of the caregiving activities, but somebody else provides care occasionally
3 I equally share caregiving activities with somebody else
4 Somebody else does most of the caregiving activities, but I provide care occasionally
ca009 (how long care given)
For how long have you been providing care to that family member or close friend?
1 I have been providing care for more than a year
2 I have been providing care for less than a year
if ca009 = 1 then
ca009_years (years how long care given)
For how many years have you been providing care to that family member or close friend?
RANGE 1..120
elseif ca009 = 2 then
ca009_months (months how long care given)
For how many months have you been providing care to that family member or close friend?
RANGE 0..12
End of if
ca010 (hours per week giving care)
How many hours per week do you spend assisting that family member or close friend?
RANGE 1..168
Group of questions presented on the same screen
ca011_intro
Has your work or schooling changed due to your caregiving responsibilities?
Subgroup of questions
ca011a (stopped working)
I stopped working
1 (YES) Yes
2 (NO) No
ca011b (changed job)
I changed job
1 (YES) Yes
2 (NO) No
ca011c (dropped out of school)
I dropped out of school
1 (YES) Yes
2 (NO) No
ca011d (cut down on hours of work/schooling)
I cut down on hours of work/schooling
1 (YES) Yes
2 (NO) No
ca011e (other changes due caregiving)
Other changes, please describe:
1 (YES) Yes
2 (NO) No
End of subgroup of questions
ca011e_other (specify other changes due caregiving)
STRING
End of group of questions
if ca011a = 1 OR ca011b = 1 OR ca011c = 1 OR ca011d = 1 OR ca011e = 1 then
ca012 (when changes occurred)
When did your work or schooling change due to caregiving responsibilities? (If more than one change, please indicate the most recent)
1 2019 or before
2 January 2020
3 February 2020
4 March 2020
5 April 2020
6 May 2020
7 June 2020
8 July 2020
9 August 2020
10 September 2020
11 October 2020
12 November 2020
13 December 2020
End of if
Group of questions presented on the same screen
ca013_intro
Have you done any of the following due to your caregiving responsibilities?
Subgroup of questions
ca013a (Missed doctor appointments)
Missed doctor appointments
1 (YES) Yes
2 (NO) No
ca013b (Reduced or stopped exercising)
Reduced or stopped exercising
1 (YES) Yes
2 (NO) No
ca013c (Reduced or stopped eating healthy meals)
Reduced or stopped eating healthy meals
1 (YES) Yes
2 (NO) No
ca013d (Reduced or stopped doing things you enjoyed)
Reduced or stopped doing things you enjoyed
1 (YES) Yes
2 (NO) No
End of subgroup of questions
End of group of questions