Effective Date: 
2/2011

Documents

Instructions

Updated: 2/2011

Purpose

The Caregiver Status Questionnaire (CSQ) is designed to meet the requirements of Senate Bill 271, which directs Texas Health and Human Services Commission (HHSC) staff to:

  • collect profile data on informal caregivers and provide referral to support services when appropriate; and
  • implement the use of a standardized caregiver assessment tool to evaluate the needs of caregivers.

Note: The information collected on the CSQ is not to be used to determine if the unmet need criteria for Community Care services has been met. The case manager will collect the information necessary to determine eligibility for services.

This information is collected and submitted to the Legislative Budget Board by December of each even-numbered year.

Procedure

When to Prepare

When possible, the CSQ will be completed at the time of the intake contact. If that is not feasible, one additional contact must be attempted. When a follow-up contact is made, indicate the date on the top right corner of the CSQ. Check the appropriate box to indicate if the attempt to contact failed or if the caregiver declined to participate.

The purpose of the CSQ is to collect the information required by Senate Bill 271. This information is not used to determine if the unmet need criteria for Community Care services has been met. The case manager will collect the information necessary to determine eligibility for services.

Transmittal and Form Retention

Form 1027/1027-S is a tool for collecting CSQ data, but is not a required form. Data may be entered directly into the Intake (NTK) System. When Form 1027/1027-S is used, staff must enter all information collected into the NTK system. Retain copies of the form according to regional requirements.

Detailed Instructions

Question Sensitivity

Some individuals may find it awkward to ask some of the questions on the CSQ. While understandable, all questions must be asked in an attempt to develop a caregiver profile. If an individual seems resistant to answering any of the questions, do not insist on a response. Continue to the next question.

Caregiver Demographics

HHSC Staff — Enter the name of the individual completing the CSQ.

Date — Enter the date the information is being collected.

Caregiver Name, Telephone, Address, City, State, ZIP Code, County — Enter the caregiver's name, telephone number, street address, city, state, ZIP code and county.

Hispanic Origin? — Check Yes, No or Refused to answer. Refused to answer may not be checked in lieu of asking the question.

What is your race? — Check the appropriate box to indicate the individual's race or check Refused to answer if the caregiver or caregiver representative did not wish to provide this information. Refused to answer may not be checked in lieu of asking the question.

What is your relationship to [care recipient]? — Check the appropriate box to indicate the individual's relation to the care receiver or check Refused to answer if the responder did not wish to provide this information.

Marital Status — Check the appropriate box to indicate the individual's marital status or check Refused to answer if the responder did not wish to provide this information.

Lives with care recipient? — Check the appropriate box to indicate whether the individual is living with the care recipient or check Refused to answer if the responder did not wish to provide this information.

Distance to care recipient's home — Check the appropriate box to indicate the distance between the homes of the caregiver and care receipient, or check Refused to answer if the responder did not wish to provide this information.

Caregiver Profile

1.  Are you paid to provide care for [care recipient's name]? — Check Yes, No or Refused to answer. If the response is Yes, the interview ends here.

2.  Are you the only non-paid person providing care to [care recipient's name]? — Check Yes, No or Refused to answer.

3.  How long have you provided care for [care recipient's name]? — Record the number of years and months.

4.  How often do you provide care for [care recipient's name]? — Check the appropriate box for Daily, Weekly, Monthly, Less than once per month or Refused to answer.

5.  Do you have children under the age of 18? — Check Yes, No or Refused to answer.

6.  Are you also providing care to any other individuals? — Check Yes, No or Refused to answer.

7.  Is there anyone you can call on in an emergency to fill in for you as caregiver? — Check Yes, No or Refused to answer.

8.  Are you employed? — Check Full-time, Part-time, Not employed or Refused to answer.If Not employed, go to question 10a.

Questions 9a and 9b, Effects on Caregiver Employment

Checkboxes have been provided as a way to record the ways caregiving responsibilities have affected the caregiver's employment. This should be asked as an open-ended question. Listen to the caregiver's comments and check the boxes that apply. Do not simply go down the list reading off each possible response.

The list can be used as a prompt if the responder is unsure how to answer. For example, if the individual seems uncertain, the questioner may reply: "For example, have you had to take extra leave or change your work schedule to meet your caregiver responsibilities? Has it affected your work performance, pay or strained your relationship with coworkers?” The check boxes may be used only if further prompts are necessary.

9a. Have your caregiver responsibilities ever affected your employment? — Check Yes, No or Refused to answer. If No, go to question 10a.

9b. How has your employment ever been affected? — Check all boxes that apply.

10a. Do you have a chronic health condition or have you experienced a recent health crisis? — Check Yes, No or Refused to answer. If No or Refused to answer is checked, go to question 11a.

10b. Has this health condition affected your ability to care for [care recipient's name]? — Check Yes, No or Refused to answer.

11a. Do you find caring for [care recipient's name] to be stressful? — Check Yes, No or Refused to answer. If No, stop.

11b. Would you rate your stress level as: — Check Low, Moderate, High or Refused to answer.

Referral to the Area Agency on Aging (AAA)

If the individual meets one of the criteria indicated on Form 1027/1027-S, he or she may qualify for services from AAA. If so, and if the individual indicates he would like assistance, make the referral according to regional procedures.

If the caregiver status form is only partially completed, explain why: — If, at any point in the interview, the responder opted not to complete the interview, explain the circumstances here.

For assistance in completing the CSQ, staff may use the CSQ script, provided in both English and Spanish.

Attachment 1 – English

Attachment 2 – Spanish

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