Statewide Respite Survey
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.
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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? *
Caregiver is currently caring for a loved one who (select applicable age) *
The loved one I am caring for has (please select all that apply) *
The most difficult part of being a caregiver is (select all that apply): *
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 currently receive support through: *
In the past year I have received respite services (select al that apply) *
If you have applied but not received services, what was the reason?
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If you have decided not to apply for respite, why?
If I had a choice, I would prefer to have respite (please select one):  *
If I had a choice, please select one:  *
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
I would be able to keep our loved one at home, if we received respite hours on a monthly basis up to (select one): *
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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