Texas Department of Aging and Disability Services
Access & Intake/Area Agencies on Aging
Instructions for completing the
Caregiver Assessment Questionnaire
stSenate Bill (SB) 271, 81 Legislature, Regular Session, 2009, relating to informal caregiver support services, directs the Department of Aging and Disability Services (DADS) to:
; raise awareness of services available to caregivers;
; perform outreach functions to informal caregivers; and
; gather information about the needs of caregivers through:
o collection of profile data on informal caregivers;
o provision of caregiver referral to support services when appropriate; and
o implementation of a standardized caregiver assessment tool to evaluate the needs
SB 271 requires DADS to use the information collected to refer informal caregivers to available support services and to:
; evaluate the needs of assessed informal caregivers;
; measure the effectiveness of certain informal caregiver support interventions;
; improve existing programs;
; develop new services as necessary to sustain informal caregivers; and
; determine the effect of informal caregiving on employment and employers. SB 271 also requires DADS to coordinate with Area Agencies on Aging (AAA) to develop and implement a protocol to evaluate the needs of certain informal caregivers. The protocol must provide guidance on the type of caregivers who should receive an assessment and include the use of a standardized assessment tool.
In collaboration with AAAs and Community Services and Program Operations Section of DADS, the Access and Intake/Area Agencies on Aging Section has developed the Caregiver Assessment Questionnaire (CAQ) which incorporates a caregiver profile being implemented by LTSS staff throughout Texas.
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A. Types of Caregivers to be Assessed
The CAQ must be completed for all caregivers receiving Care Coordination or Caregiver
Support Coordination funded through Title III-E of the Older Americans Act (OAA). For
example, Respite Vouchers or authorization of Adult Day Care occurs under Care
Coordination or Caregiver Support Coordination so the completion of the Caregiver
Assessment is required for caregivers receiving these services under Title III-E. B. Standardized Assessment Tool
The CAQ is used to:
; collect various types of data designed to evaluate the needs of informal caregivers;
; collect data in a uniform manner from all AAAs; and
; provide consistent caregiver data to DADS for evaluation.
The CAQ is designed to meet the requirements of SB 271. The information collected will be
analyzed and will be included in DADS’ report to the governor and the Legislative Budget
Board. DADS is required to submit this report in December of each even-numbered year,
beginning December 1, 2012.
Completing the Paper Form
The CAQ is required to be completed at intake when Care Coordination or Caregiver Support Coordination is identified as a need for a caregiver requesting assistance. The CAQ must be completed for each unduplicated caregiver based on the state fiscal year. This form may be completed by AAA staff during a face-to-face interview or by telephone. The AAA staff must discuss the questions with the caregiver. The caregiver may not be requested to complete the form by themselves and return the form to the AAA.
A. Question Sensitivity
Staff may find it awkward to ask certain questions on the CAQ. While understandable, all
questions must be asked and a response recorded for each. It is not acceptable to skip a
question. If an individual seems resistant to answering any of the questions, do not insist on a
response. Simply document the individual refused to answer and continue to the next
B. Caregiver Employment
Check boxes have been provided as a means to record the ways caregiving responsibilities
have affected the caregiver’s employment. After asking the open-ended question, staff should
listen to the caregiver’s comments and check all of the boxes that apply. Interviewers are not
expected to read aloud each possible response to the employment question; however, the list
can be used as a prompt if the responder is unsure how to answer. If the individual seems
uncertain, read aloud the response category headings. For example, “has caregiving affected
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your employment schedule, pay, leave, performance, or work relationships?” If further
clarification is necessary considering asking: “For example, have you had to take extra leave
or change your work schedule to meet your caregiver responsibilities?”
C. Caregiver Stress Interview
In this section, check boxes have also been provided as a means to record the level of stress a
caregiver may be feeling because of caregiving responsibilities. Engaging in a dialogue with
the caregiver can be an effective way to determine the level of stress a caregiver is
experiencing for a given area. Ask open-ended questions. Approaching this area in a
conversational manner can alleviate discomfort in asking these questions for both the staff
and the caregiver.
It is important to keep in mind the most complete and accurate information gained while completing the CAQ will result in DADS’ best analysis on a statewide level for reporting to the governor and Legislative Budget Board. More importantly, the AAA staff discussion with the caregiver may identify the best ways to help serve the caregiver.
Entering the CAQ Responses into SAMS
Each AAA is required to enter the CAQ responses into SAMS using the assessment function. The assessment document in SAMS mirrors the questions and responses on the paper form. The AAA is not required to complete a paper form if the environment allows for direct entry of the responses into SAMS.
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1. Caregiver’s first name: 5. Caregiver’s relationship to care recipient:
Other Relative 2. Caregiver’s last name: Child
Other Non-Relative Friend
Sibling Grandchild 3. Care recipient’s first name: Son/Daughter-in-Law Grandparent
Spouse Life Partner 4. Care recipient’s last name: Refused to Answer Neighbor
6. Caregiver Demographics and Living Arrangement 7. Assessment Time Start:
8. Assessment Time End: a. Marital Status: Married Not Married Refused
b. Hispanic Origin: Yes No Refused
c. Race: Asian Black Native Hawaiian 9. Total Time: d. Lives with care recipient: White Refused Other Pacific
Yes No Refused
10. Were you aware of the caregiver support resources prior to making this contact? Yes No 11. If YES, have you received caregiver support services in the past? Yes No 12. If NO, what prompted you to seek help now?
13. Do you have concerns about receiving the caregiver support? (Check all that apply)
Care recipient reluctant to accept outside help No one else can provide care as well as I do
Do not trust service providers in the home Other
14. If “Other” was indicated above, please describe:
15. Are you paid to provide care for [care recipient’s name]? Yes No (If Yes, stop here)
Yes No 16. Are you the only non-paid person providing care to [care recipient’s name]? Refused to Answer 17. How long have you provided care for [care recipient’s name]? year(s) month(s) 18. How often do you provide care to [care recipient’s name]?