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Questionnaire for Carers
What to do:
It is your own views and experiences we want to hear about and not the views of
someone you may care for. We will capture the views of people who are cared for
separately.
If a question is not relevant to you, then please leave that question blank.
If you want to, please add any comments in the space below the statement about
your answers.
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Unique Reference
Your answer
Thinking about your life at the moment, do you agree with the following:
1. I live in a home that best supports my well-being. For example, it is the right home for your current needs
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
2. I can do the things that are important to me
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
3. I feel I am part of my community
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
4. I am happy with the support from my family, friends and neighbours
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
5. I feel safe - For example, safe from any kind of abuse, physical harm or from falling both insideand outside your home
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
Thinking about the support you have had as a carer, do you agree with the following:
6. I know who to contact about my support
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
7. I have had the right information or advice when I needed it
Yes
Sometimes
No
Don't know
Clear selection
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Your answer
8. I have been actively involved in decisions about how my support was provided
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
9. I have been involved in all decisions about how the care and support was provided for the person I care for
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
10. I was able to communicate in my preferred language. For example, using English, Welsh, Polish, Bengali or any other language
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
11. I was treated with dignity and respect
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
12. I feel supported to continue in my caring role
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
13. I am happy with the support I have had
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
14. Please only answer this question if you are aged 18-24 years old:I have had advice, help and support that will prepare me for adulthood
Yes
Sometimes
No
Don't know
Clear selection
Please add any comments if you would like to:
Your answer
A little about you…..
15. Are you?
Male
Female
Prefer not to say
Clear selection
16. How old are you?
18-24 years old
25-64 years old
65-84 years old
85+ years old
Clear selection
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