Q01
Long Text
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Pediatric Caregiver Experience & Support Needs Assessment
Assesses caregiver strain, care coordination challenges, and support needs among adult caregivers of children receiving medical care to inform improvements in family-centered services.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
30 questions · ~4 min
Q02
Multiple Choice
Are you an adult (18 or older) who currently serves as a primary caregiver for a child receiving medical care?
Q03
Long Text
What is the age of the child you primarily care for?
Q04
Long Text
Overall, how much strain have you felt as a caregiver in the past 30 days?
Q05
Long Text
Approximately how many different healthcare providers has the child seen in the past 6 months?
Q06
Long Text
How helpful has your child's healthcare team been as a source of support in the past 6 months?
Q07
Long Text
Overall, how satisfied are you with the quality of care your child has received?
Q08
AI Interview
Thinking about your overall caregiving experience, what has been the biggest gap in the support available to you, and what would make the most difference going forward?
Q09
Long Text
What is your age?
Q10
Long Text
Thank you for sharing your experiences. Your responses are valuable and will be used to improve support services for caregivers and families. If you have any questions about this study, please contact [research team email].
Q11
Multiple Choice
What is your relationship to the child you primarily care for?
Q12
Long Text
How often do you manage the child's medications or treatments?
Q13
Long Text
Please rank your top 3 care coordination challenges, from most to least challenging.
Q14
Long Text
How helpful have family and friends been as a source of support in the past 6 months?
Q15
Long Text
Overall, how well-supported do you feel as a caregiver by the healthcare system?
Q16
Multiple Choice
What is your gender?
Q17
Multiple Choice
Which of the following best describe the child's health needs? (Select all that apply.)
Q18
Long Text
How often do you coordinate medical appointments or therapies for the child?
Q19
Long Text
How easy is it to find clear information about the child's care plan and instructions?
Q20
Long Text
How helpful have community or online support groups been in the past 6 months?
Q21
Long Text
How likely are you to recommend your child's primary healthcare provider to another caregiver in a similar situation?
Q22
Long Text
Which region do you live in?
Q23
Long Text
In a typical week, approximately how many hours do you spend on caregiving tasks (e.g., medical care, therapy, care coordination) for this child?
Q24
Long Text
How often do you assist with the child's daily personal care needs (e.g., bathing, feeding, mobility)?
Q25
Long Text
How helpful have care coordinators, case managers, or social workers been in the past 6 months?
Q26
Long Text
What is the highest level of education you have completed?
Q27
Long Text
How often do you advocate for the child's needs with schools, insurers, or other organizations?
Q28
Multiple Choice
Which support formats would be most useful to you going forward? (Select all that apply.)
Q29
Multiple Choice
What is your current employment status?
Q30
Multiple Choice
Which areas of your life have been most affected by caregiving in the past 30 days? (Select all that apply.)
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.