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.
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
Template Overview
30
Questions
AI-Powered
Smart Analysis
Ready-to-Use
Launch in Minutes
This professionally designed survey template helps you gather valuable insights with intelligent question flow and automated analysis.
Sample Survey Items
Q1
Chat Message
Welcome, and thank you for your interest in this survey.
This study explores the experiences and support needs of adult caregivers of children receiving medical care. It takes approximately 8–10 minutes to complete.
Your participation is entirely voluntary, and you may stop at any time without consequence. There are no right or wrong answers — we are interested only in your honest opinions and experiences.
All responses are confidential, will be anonymized, and reported only in aggregate to inform improvements in family-centered care services.
Please answer based on your experience with one child you primarily care for. By continuing, you indicate your consent to participate.
Q2
Multiple Choice
Are you an adult (18 or older) who currently serves as a primary caregiver for a child receiving medical care?
Yes
No
Q3
Dropdown
What is the age of the child you primarily care for?
Under 1 year
1–3 years
4–6 years
7–12 years
13–17 years
18 or older
Q4
Multiple Choice
What is your relationship to the child you primarily care for?
Parent
Step-parent
Grandparent
Foster parent or legal guardian
Adult sibling (18+)
Other caregiver
Prefer not to say
Q5
Multiple Choice
Which of the following best describe the child's health needs? (Select all that apply.)
Chronic physical condition
Developmental disability
Behavioral or mental health condition
Acute or short-term condition
Rare disease
Medically complex (multiple conditions)
Not sure
Prefer not to say
Other (please specify)
Q6
Dropdown
In a typical week, approximately how many hours do you spend on caregiving tasks (e.g., medical care, therapy, care coordination) for this child?
Less than 5 hours
5–10 hours
11–20 hours
21–40 hours
More than 40 hours
Not sure
Q7
Opinion Scale
Overall, how much strain have you felt as a caregiver in the past 30 days?
Range: 1 – 5
Min: No strain at allMid: NeutralMax: Extreme strain
Q8
Opinion Scale
How often do you manage the child's medications or treatments?
Range: 1 – 5
Min: NeverMid: NeutralMax: Multiple times daily
Q9
Opinion Scale
How often do you coordinate medical appointments or therapies for the child?
Range: 1 – 5
Min: NeverMid: NeutralMax: Multiple times daily
Q10
Opinion Scale
How often do you assist with the child's daily personal care needs (e.g., bathing, feeding, mobility)?
Range: 1 – 5
Min: NeverMid: NeutralMax: Multiple times daily
Q11
Opinion Scale
How often do you advocate for the child's needs with schools, insurers, or other organizations?
Range: 1 – 5
Min: NeverMid: NeutralMax: Multiple times daily
Q12
Multiple Choice
Which areas of your life have been most 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
None of the above
Other (please specify)
Q13
Dropdown
Approximately how many different healthcare providers has the child seen in the past 6 months?
1
2–3
4–6
7–10
More than 10
Not sure
Q14
Ranking
Please rank your top 3 care coordination challenges, from most to least challenging.
Drag to order (top = most important)
Scheduling appointments
Getting information shared between providers
Repeating the child's history at each visit
Insurance approvals or authorizations
Transportation or distance
Finding the right specialist
Q15
Opinion Scale
How easy is it to find clear information about the child's care plan and instructions?
Range: 1 – 5
Min: Very difficultMid: NeutralMax: Very easy
Q16
Opinion Scale
How helpful has your child's healthcare team been as a source of support in the past 6 months?
Range: 1 – 5
Min: Not at all helpfulMid: NeutralMax: Extremely helpful
Q17
Opinion Scale
How helpful have family and friends been as a source of support in the past 6 months?
Range: 1 – 5
Min: Not at all helpfulMid: NeutralMax: Extremely helpful
Q18
Opinion Scale
How helpful have community or online support groups been in the past 6 months?
Range: 1 – 5
Min: Not at all helpfulMid: NeutralMax: Extremely helpful
Q19
Opinion Scale
How helpful have care coordinators, case managers, or social workers been in the past 6 months?
Range: 1 – 5
Min: Not at all helpfulMid: NeutralMax: Extremely helpful
Q20
Multiple Choice
Which support formats would be most useful to you going forward? (Select all that apply.)
In-person support groups
One-on-one counseling
Phone hotline
Text or chat support
Mobile app tools
Printed guides
Video tutorials
Live webinars
Peer mentor matching
None of the above
Other (please specify)
Q21
Opinion Scale
Overall, how satisfied are you with the quality of care your child has received?
Overall, how well-supported do you feel as a caregiver by the healthcare system?
Range: 1 – 7
Min: Not at all supportedMid: NeutralMax: Extremely well supported
Q23
Opinion Scale
How likely are you to recommend your child's primary healthcare provider to another caregiver in a similar situation?
Range: 0 – 10
Min: Not at all likelyMid: NeutralMax: Extremely likely
Q24
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?
AI InterviewLength: 3Personality: [Object Object]Mode: Fast
Reference questions: 7
Q25
Dropdown
What is your age?
18–24
25–34
35–44
45–54
55–64
65 or older
Prefer not to say
Q26
Multiple Choice
What is your gender?
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Q27
Dropdown
Which region do you live in?
Africa
Asia
Europe
North America
South America
Oceania
Prefer not to say
Q28
Dropdown
What is the highest level of education you have completed?
Less than high school
High school or equivalent
Some college or associate degree
Bachelor's degree
Graduate or professional degree
Prefer not to say
Q29
Multiple Choice
What is your current employment status?
Employed full-time
Employed part-time
Self-employed
Homemaker or full-time caregiver (not employed)
Student
Unemployed, seeking work
Retired
Unable to work
Prefer not to say
Q30
Chat Message
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].
Frequently Asked Questions
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