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Pediatric Caregiver Experience & Support Survey Template

Collect parent and caregiver feedback on pediatric care, support needs, and satisfaction. Customizable template to improve family-centered services.

What's Included

AI-Powered Questions

Intelligent follow-up questions based on responses

Automated Analysis

Real-time sentiment and insight detection

Smart Distribution

Target the right audience automatically

Detailed Reports

Comprehensive insights and recommendations

Sample Survey Items

Q1
Chat Message
Welcome! This survey is for adult caregivers of children receiving medical care. It takes about 8–10 minutes. Please answer based on your experience with one child you mainly care for.
Q2
Dropdown
What is the child’s age?
  • Under 1 year
  • 1–3 years
  • 4–6 years
  • 7–12 years
  • 13–17 years
  • 18 or older
Q3
Multiple Choice
What is your relationship to the child you mainly care for?
  • Parent
  • Step-parent
  • Grandparent
  • Foster parent/guardian
  • Adult sibling (18+)
  • Other caregiver
  • Prefer not to say
Q4
Multiple Choice
Which of the following best describe the child’s health needs? Select up to 3.
  • Chronic physical condition
  • Developmental disability
  • Behavioral/mental health
  • Acute or short-term condition
  • Rare disease
  • Medically complex (multiple conditions)
  • Not sure
  • Prefer not to say
  • Other
Q5
Numeric
In a typical week, approximately how many hours do you provide care for this child?
Accepts a numeric value
Whole numbers only
Q6
Opinion Scale
Overall, how much strain have you felt as a caregiver in the past 30 days?
Range: 1 – 10
Min: No strainMid: ModerateMax: Extreme strain
Q7
Matrix
How often do you perform each of the following caregiving tasks for the child?
RowsNeverMonthly or lessA few times a monthWeeklySeveral times/weekDaily
Give medications or treatments••••••
Monitor symptoms or track data••••••
Therapy or home exercises••••••
Insurance or billing paperwork••••••
Scheduling and transport to visits••••••
Coordinating with school or services••••••
Q8
Multiple Choice
Which areas of your life have been affected by caregiving in the past 30 days? Select all that apply.
  • Sleep
  • Work or school
  • Finances
  • Social life
  • Mental health
  • Physical health
  • Family relationships
Q9
Numeric
Approximately how many different healthcare providers has the child seen in the past 6 months? Please enter a whole number.
Accepts a numeric value
Whole numbers only
Q10
Ranking
Rank your biggest coordination challenges (drag to order).
Drag to order (top = most important)
  1. Scheduling appointments
  2. Getting information shared between providers
  3. Repeating the child’s history
  4. Insurance approvals/authorizations
  5. Transportation or distance
  6. Finding the right specialist
Q11
Rating
How easy is it to find clear instructions and information about the child’s care?
Scale: 10 (star)
Min: Very hardMax: Very easy
Q12
Multiple Choice
Attention check: To confirm you are paying attention, please select “I am paying attention.”
  • I am paying attention
  • I am not paying attention
  • Prefer not to say
Q13
Matrix
How helpful have these supports been in the past 6 months?
RowsNot usedNot helpfulSlightly helpfulModerately helpfulVery helpful
Respite care•••••
Hospital social work or case management•••••
Care team messaging or telehealth•••••
Peer support groups•••••
School-based services•••••
Financial assistance programs•••••
Q14
Multiple Choice
Which support formats would be most useful to you? Select all that apply.
  • In-person groups
  • One-on-one counseling
  • Phone hotline
  • Text or chat support
  • Mobile app tools
  • Printed guides
  • Video tutorials
  • Live webinars
  • Peer mentor match
Q15
Long Text
Briefly describe the biggest support gap you’ve faced in the past 6 months.
Max 600 chars
Q16
Long Text
Is there anything else you’d like us to know about your caregiving experience?
Max 600 chars
Q17
AI Interview
AI Interview: 2 Follow-up Questions on Caregiver Support Needs
AI InterviewLength: 2Personality: Expert InterviewerMode: Fast
Reference questions: 13
Q18
Dropdown
What is your age?
  • 18–24
  • 25–34
  • 35–44
  • 45–54
  • 55–64
  • 65+
  • Prefer not to say
Q19
Multiple Choice
What is your gender?
  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q20
Dropdown
Which region do you live in?
  • Africa
  • Asia
  • Europe
  • North America
  • South America
  • Oceania
  • Prefer not to say
Q21
Dropdown
What is the highest level of education you have completed?
  • Less than high school
  • High school or equivalent
  • Some college or associate
  • Bachelor’s degree
  • Graduate or professional degree
  • Prefer not to say
Q22
Multiple Choice
What is your current employment status?
  • Employed full-time
  • Employed part-time
  • Self-employed
  • Homemaker/caregiver not employed
  • Student
  • Unemployed seeking work
  • Retired
  • Unable to work
  • Prefer not to say
Q23
Chat Message
Thank you for your time and insights—your responses will help improve support for caregivers.

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