Caregiver Assessment Forms and Instructions

These are part of the Pennsylvania Department on Aging’s Comprehensive Options

Assessment instrument. The other major content areas are:

• Physical Health
• Activities of Daily Living
• Mobility
• Instrumental Activities of Daily Living
• Nutrition
• Social Participation
• Cognitive Functioning
• Emotional Status and Behavior
• Formal Services
• Physical Environment
• Financial Resources
• Preferences
• Decision Narrative
• Placement Options Information

The Informal Support and Caregiver Stress Interview forms and instructions follow:
 Revised 11/97
SECTION 9: INFORMAL SUPPORTS

1. Does consumer have any informal supports?

No, Skip to page 17, Section 10, Question 1. Yes, continue . . .

Relationship
2. List Informal Supports P = Primary NARRATIVE:
Name/Location/Phone caregiver Age Help Provided

3. If the people who help you are not available, are there other persons who will assist you if asked? Yes No
Who are they?
__________________________________________________________________________________

4. Check limitations or constraints on primary caregiver.

No particular constraints Poor relationship with consumer

Poor health, disabled, frail Lives at a distance
Employed Alcohol, drug abuse
Lacks knowledge, skills Financial strain
Providing care to others Dependent on consumer for housing, money or other
Not reliable

PRIMARY CAREGIVER INFORMATION (important when considering FCSP)

5. Current employment status? (full/part time)

__________________________________________________________________

6. Have your caregiving and social life and/or employment affected each other? How?
_____________________________________________________________________________________

_____________________________________________________________________________________

7. Do you have any other caregiving responsibilities? (children, other adults, etc.)

8. How many hours a day do you have available to provide care to this consumer?

9. How many hours a day do you usually spend providing care to this consumer?

10. Describe problems with continued caregiving (if any).

11. Overall, how stressed do you feel in caring for the consumer? (Optional caregiver stress interview may be
completed at this point in the assessment - see pg. 25)
Not stressed Somewhat stressed Very stressed

12. Do you desire service or support?

No Yes, Describe needs

13. Is anyone available to provide respite (relief) when you are unable to provide care? _____ Yes _____ No If
yes, is such assistance available on short notice? ____ Yes _____ No

14. In the past six months, have there been any significant changes or events in your life?
_____ Yes _____ No Explain:

15. Are you currently experiencing any emotional concerns or difficulties? _____ Yes _____ No Explain:

16. Are you currently receiving any assistance to deal with your emotional concerns or difficulties?
_____ Yes _____ No
Explain:

17. Do you participate in a support or discussion group where you can discuss your feelings?
_____ Yes _____ No
What type of support group/frequency of attendance?

18. Have you ever been so upset that you did something to your relative (consumer) that you now regret?
_____ Yes _____ No
Explain:

19. Has your relative (consumer) ever done these kinds of things to you? ______ Yes _____ No Explain:
20. Consumable Caregiving Supplies

Item Description Total Average Who Pays

Monthly Costs

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

21. What is the average monthly cost TO THE FAMILY OR CONSUMER for consumable supplies?

22. Comments
 SECTION 9: INFORMAL SUPPORTS

The presence of family, friends or neighbors who are available to provide help can have a great impact
on a consumer's ability to remain at home. This section of the instrument is not intended to measure the
level of socialization or companionship provided by family or friends. Rather, this section asks about
persons who provide services or care to the consumer, including ADL assistance (bathing, dressing,
transfer, etc.), IADL assistance (cooking, cleaning, shopping, transportation, etc.), supervision and
monitoring of the consumer's condition, and/or medical services such as bandage changes, therapeutic
exercises, injections, etc. Some of this information may be recorded in other sections of the
assessment. For example, tasks performed by informal helpers may be recorded in the Physical Health,
ADL and IADL narrative sections. Although it is not necessary to repeat this information on the Informal
Supports page, cross-reference notes should be made. This page should be used to describe the help
provided and the suitability of informal helpers to perform or continue to perform the tasks in caring for
the consumer.

CURRENT INFORMAL SUPPORTS/HELPERS

1. The first section provides a place to record information regarding current or potential helpers.
Record the name, address, and phone number of each helper the consumer mentions. If the
consumer mentioned an informal helper earlier in the interview, record information without asking.
This information can also be obtained from the caregiver her/himself.

Record the relationship of each helper to the consumer in the block provided and note the
primary caregiver. The interviewer may want to use a list of abbreviations, such as:

Sp = spouse Sib = sibling

Ch = child Gr = grandchild
Ggc = great grandchild Rel = other relative
Fr = friend Nb = neighbor
Vol = volunteer Dil = daughter-in-law
Sil = son-in-law

2. The ability of the primary caregiver to continue in a caregiving role should be evaluated. Ask the
consumer and use other collateral resources to determine if there is any evidence that caregiver
is experiencing limitations or constraints in providing care and check appropriate box.

5 - 19 - Ask of primary informal caregiver only. The information obtained from these
questions applies to all, but are particularly important when considering FCSP.
 Caregiver Stress Interview (Steven H. Zarit, Ph.D. - modified version)

Read to Caregiver: The following is a list of statements which reflect how people sometimes feel when taking care
of another person. After each statement, indicate how often you feel that way: never, rarely, sometimes, quite
frequently, or nearly always. There are no right or wrong answers.

QUESTION Quite Nearly

Never Rarely Sometimes Frequently Always
1. Do you feel that your relative asks for more help than he/she needs?

2. Do you feel that because of the time you spend with your relative that you
don’t have enough time for yourself?
3. Do you feel stressed between caring for your relative and trying to meet
other responsibilities for your family or work?
4. Do you feel embarrassed over your relative’s behavior?

5. Do you feel angry when you are around your relative?

6. Do you feel that your relative currently affects your relationship with other
family members or friends in a negative way?
7. Are you afraid of what the future holds for your relative?

8. Do you feel your relative is dependent upon you?

9. Do you feel strained when you are around your relative?

10. Do you feel your health has suffered because of your involvement with
your relative?
11. Do you feel that you don’t have as much privacy as you would like
because of your relative?
12. Do you feel that your social life has suffered because you are caring for
your relative?
13. Do you feel uncomfortable about having friends over because you are
caring for your relative?
14. Do you feel that your relative seems to expect you to take care of him/her
as if you were the only one he/she could depend on?
15. Do you feel that you don’t have enough money to care for your relative in
addition to the rest of your expenses?
16. Do you feel that you will be unable to take care of your relative much
longer?
17. Do you feel you have lost control of your life since your relative’s illness?

18. Do you wish you could just leave the care of your relative to someone
else?
19. Do you feel uncertain about what to do about your relative?

20. Do you feel you should be doing more for your relative?

21. Do you feel you could do a better job in caring for your relative?

22. Overall, do you feel burdened caring for your relative?

To be completed by Case Manager:

TOTAL ZARIT SCORE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _____________

 Caregiver Stress Interview (Steven H. Zarit, Ph.D. - modified version)

SCORING INSTRUCTIONS

The Stress Interview is scored by summing the responses of the individual items. Higher scores
indicate greater caregiver distress (Never = 0, Rarely = 1, Sometimes = 2, Quite Frequently = 3,
Nearly Always = 4). The Stress Interview, however, should not be taken as the only indicator of
the caregiver’s emotional state. Clinical observations and other instruments such as measures
of depression should be used to supplement this measure. Norms for the Stress Interview have
not been computed, but estimates of the degree of stress can be made from preliminary findings.

These are:

0 - 20 = Little/No Stress 21 - 40 = Mild/Moderate

41 - 60 = Moderate/Severe Stress 61 - 88 = Severe Stress

If utilized, results from this instrument can be transferred as indicated to the caregiver stress
section of the Functional Needs Measurement.