1. Do you or does any member of your household work for any of the following?

A market research firm
An advertising agency
A nursing home or assisted care facility
A pharmaceutical or health care product company
None of the above

2. What is the nature of the caregiving you provide for your family member? He or she….
Lives with us in our home
Lives in their own home close by and I visit there daily
Lives in their own home close by and I visit there weekly
Lives in their own home far distant and I visit there occasionally
They live in a nursing home or assisted care facility

3. What type of pharmacist do you use most often for the purchase of medical supplies and drugs?

Independent store
Pharmacy chain store (e.g. CVS, Rite Aid)
Other type of chain store (Supermarket, Wal-Mart)
Internet source

4. Why do you use that type of pharmacist most often?
(Please check all those responses that apply)

Lower prices
Convenience of location
Advice or guidance provided by pharmacist
Operating hours
Delivery service
Acting when doctor not available
Other (Specify )
Don't Know

5. If you tried to change your family member’s medication to a generic brand, what was the family member’s reaction?

Not applicable, they still use branded medication
Very strong resistance, they will not change
Some resistance and they still will not change
Some resistance, but they accepted change
No problem, they accepted change

6. To what extent is the cost of medical care for your family member covered by insurance?

Most of the cost (90 to 100%)
A high proportion (56 to 89%)
About half is covered (45 to 55%)
Some (11 to 44%)
Very little or none (0 to 10%)

7. How much do you contribute towards the cost of caregiving of your family member?

Almost all of it
More than one half but not all
About half
Between one half and zero
None

8. Has taking care of your family member’s financial and medical needs changed your retirement planning?

Yes No

9. Do you use the services of a professional financial planner to assist you in coping with this issue?

Yes No

10. How would you describe your participation in the decision to move into a nursing home or assisted care?

Not applicable, they have not moved I was not involved; they made the decision on their own	Please skip ahead to Question 13
It was a mutual decision with equal input from all sides I pressed for the move, but with their agreement I really insisted on the decision	Please continue with Question 11

11. What three factors did you consider in selecting a nursing home or assisted care facility for your family member?
(Check any three answers from the selection below)

Cost
Proximity to your home
Proximity to a good hospital
Quality of food at the facility
Quality of the facility staff
Medical services offered
Activities offered
Appearance / Ambience
Recommended by doctor
Recommended by hospital
Recommended by others
Other (Specify )


12. Please describe your feelings, both now and at the time the decision was made, about moving your family member to a nursing home or assisted care facility? (Please check one answer only in each column)

13. Some of the issues in the table below are considered the most emotionally distressing in the caregiving process. Please rank each one on a scale of 1 to 5, with 5 as the most distressing and 1 as the least
(Please check only one ranking in each row)

Caregiving Issue	Most Distressing		Least Distressing	Don't Know
	5   4	3	2   1
Dealing with being the “parent” rather than the child
Balancing my other family responsibilities
Handling work / life issues
Financial burdens or future considerations
Nursing home or assisted living considerations

14. Please indicate your gender? Male Female

15. Please indicate the age group you belong to?
(Please check only one answer)

Up to 45
46 to 55
56 to 65
Over 65
Refused

16. Please indicate your total household income
(Please check only one answer)

Less than $50,000
$50,000 to 74,999
$75,000 to $99,999
$100,000 to $150,000
More than $150,000
Refused

Thank you for your time in sharing your opinions with us. Please take a moment and check that you have answered all questions.

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