TCAP Questionnaire

Internal Use: WPRT

P.O. Box 1206

Charlestown, RI 02813
(401) 364-9100

Toll-free (877) 595-6227

NEW MEMBER QUESTIONNAIRE

Dear Caregiver,

Thank you for taking the time to join TCAP. Please complete the following New Member Questionnaire

and return it to the address above. We look forward to your participation.

Paul Alper, President and Founder

Instructions: Please PRINT using blue or black ink.
1. Are you currently providing any care or assistance to a person who needs help as a result of an illness, a disability, or the aging process? ¨1 YES è Please continue. ¨2 NO è Your survey is now complete. Thank you for your interest in TCAP. 2. Are you being paid to provide care? ¨2 Yes ¨1 No
3. How did you hear about this panel?
	¨02 Health professional / home health aide			¨07 Friend/relative
	¨30 Medical Supply Store - name: _____________________			¨35 Telephone recruitment call
	¨31 Product insert from: _____________________________			¨36 TCAP Postcard
	¨04 Today’s Caregiver Magazine			¨37 Exceptional Parent Magazine
	¨32 TCAP panel member - please tell us who: ________________________________________
	¨33 Web site - please specify: _____________________________________________________
	¨34 Caregiver group or support group - please specify group:
		¨17 NFCA	¨09 WellSpouse Foundation
		¨10 CAPS	¨40 Other: __________________________________
	¨38 Ad or article in magazine/newspaper - please specify: ______________________________
	¨39 Conference/lecture/talk - please specify: _________________________________________
	¨06 Other - please specify: _______________________________________________________

4. Please tell us how to contact you First Name _____________________ Middle______________ Last_______________________________ Address _______________________________________________________________________________ City___________________________________________ State_________________ Zip______________ 5. Title (check one) ¨1 Miss ¨2 Ms. ¨3 Mrs. ¨4 Mr. ¨5 Rev. ¨6 Dr. ¨7 Other ________________ 6. Home phone number ( _______ ) _______________________________ 7. E-mail address (if applicable) ___________________________________ 8. Are you willing and able to participate in studies over the Internet/on line? ¨1 Yes ¨2 No 9. Your date of birth Month______ /Day______ /Year__________ (Example 05/16/1957) 10. Your sex ¨1 Male ¨2 Female

11. Your marital status

¨1 Married or living with partner ¨2 Single, never married ¨3 Widowed ¨4 Divorced/separated

12. Are you employed (outside of your caregiving responsibilities)?

¨1 Yes, full time ¨2 Yes, part time ¨3 Yes, self-employed ¨4 No, retired ¨5 No, not employed

13. Do you own your home? ¨1 Yes ¨2 No

14. Are you a caregiver for more than one person? (as a result of illness, disability, or aging)	¨1 Yes è	How many do you care for?_______
	¨2 No

	First Person		Second Person
15. First name of person cared for:		_________________________	16. __________________________
a. Person’s date of birth (Example: 05/16/1957)	Month____/Day____/Year_____		a. Month____/Day____/Year_____
b. Sex	¨1 Male ¨2 Female		b. ¨1 Male ¨2 Female
c. Relationship to you	¨1 Your Spouse/Partner ¨2 Your Parent/In-law ¨3 Your Sibling/In-law ¨4 Your Child ¨5 Other Relative ¨6 Non-related friend ¨7 Your client (for paid caregiver) ¨8 Other (please specify) _______________________		c. ¨1 Your Spouse/Partner ¨2 Your Parent/In-law ¨3 Your Sibling/In-law ¨4 Your Child ¨5 Other Relative ¨6 Non-related friend ¨7 Your client (for paid caregiver) ¨8 Other (please specify) _______________________
d. Is that person employed?	¨1 Yes, full time ¨2 Yes, part time ¨3 Yes, now on medical leave ¨4 No, now on disability ¨5 No, retired ¨6 No, not currently employed		d. ¨1 Yes, full time ¨2 Yes, part time ¨3 Yes, now on medical leave ¨4 No, now on disability ¨5 No, retired ¨6 No, not currently employed
e. Approximate height and weight (please estimate)	Height: ____ feet ____ inches Weight: _______ pounds		Height: ____ feet ____ inches Weight: _______ pounds

17. How many members of your household are UNDER AGE 18, (not counting you or the person you

care for)? (Enter #) ___ ___

18. How many members of your household are AGE 18 OR OLDER, (not counting you or the person you

care for)? (Enter #) ___ ___

**NOTE: PLEASE FILL OUT ALL REMAINING QUESTIONS BASED ONLY ON THE
FIRST PERSON LISTED ABOVE (IN Q15).

19. What type of residence does the person you care for live in?

¨1 Nursing home	¨3 Assisted living facility
¨2 Private home or apartment	¨4 Other (please specify) __________________________

20. Do you and the person you care for live in the same household?
¨1 Yes ¨2 No

(Skip to Q22) ê

How many adults age 18 or older live with the care recipient in
his/her household? (Enter #) ___ ___ OR ¨98 Many (group/institutional setting)

21. How long does it typically take to travel to the residence of the person you care for?

¨1 Less than
20 minutes

¨2 20 minutes to 1 hour

¨3 Over 1 hour
to 2 hours

¨4 Over 2 hours

22. What is the nature of the condition(s) of the person you are caring for?
(Please read all conditions and check ALL that apply)

¨1	ALS (Lou Gehrig’s Disease)	¨26	Heart disease/angina
¨2	Alzheimer’s/dementia	¨27	High blood pressure
¨3	Amputation	¨28	HIV/AIDS
¨4	Anemia	¨29	Impaired hearing
¨5	Arthritis	¨30	Impaired vision
¨6	Asthma/bronchitis	¨31	Incontinence: bladder
¨7	Autism	¨32	Incontinence: bowel
¨8	Birth defects	¨33	Kidney disease
¨9	Bone/joint fractures or repairs	¨34	Mental illness
¨10	Cancer	¨35	Mental retardation/developmental disabilities
¨11	Catheter	¨36	Multiple Sclerosis (MS)
¨12	Cerebral Palsy (CP)	¨37	Nutritional deficit
¨13	Chronic pain	¨38	Osteoporosis
¨14	Circulation problems/vascular disease

Second Person