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Demographics

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Greetings! Researchers at Mayo Clinic are seeking survey responses from adults 55+ who care for a loved one with a serious advanced illness. The questions that follow are about feelings of emotional distress and loss. There are a lot of losses that can happen when we assume the role of caregiver, and sometimes even beforehand, that can have a cumulative effect. Examples include loss or change in our relationships, loss of freedom, health, or financial security. Keeping these multiple experiences in mind, answer in relation to a time when it was the worst.

The survey will take approximately 5-10 minutes to complete and will help us determine if you meet the criteria to be in our study. Your participation is completely voluntary and you're free to change your mind at any time.

Please click here to view a brief, optional video about the research: Caregiver Support Study

Name:

* must provide value

Email:

* must provide value

Phone:

* must provide value

What is your current age?

* must provide value

Which site are you affiliated with?

* must provide value

Mayo Clinic Jacksonville

Mayo Clinic Rochester

Season's Hospice (Rochester)

Mayo Clinic Health Systems

Mayo Clinic Hospice (Rochester)

Community Hospice and Palliative Care (Florida)

Suncoast Hospice (Florida)

Mayo Clinic Arizona

Community setting

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If other, please specify:

What is your relationship to the person you care for:

* must provide value

I am the parent

I am the child

I am the spouse/significant other

Other

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If other, please specify:

* must provide value

What is your gender?

* must provide value

Male

Female

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What is your marital status?

* must provide value

Single

Married/ Partnered

Divorced

Separated

Widowed

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What is your race?

* must provide value

American Indian/ Alaskan Native

Asian

Black/ African American

Native Hawaiian/ Pacific Islander

White/ Caucasian

2 or more races

Unknown

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What is your ethnicity?

* must provide value

Hispanic or Latino

Not hispanic or Latino

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What is the highest level of education you have completed (please choose one)?

* must provide value

Less than high school

High school graduate / GED

Some college or vocational school

4 year college graduate

Graduate degree

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Do you have a history of vertigo or dizziness?

Yes

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Are you the primary caregiver for an immediate family member with a serious, advanced illness?

* must provide value

Yes

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How long (in months) have you been a caregiver for your loved one?

* must provide value

What are some of your caregiver responsibilities?

* must provide value

Is there anyone that helps with your caregiver responsibilities (respite provider, other family members, etc)?

* must provide value

Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.