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.
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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.
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Sample questions
A preview of what’s in the template. Every question is editable before you launch.
Are you an adult (18 or older) who currently serves as a primary caregiver for a child receiving medical care?
- Yes
- No
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
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
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)
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
Overall, how much strain have you felt as a caregiver in the past 30 days?
How often do you manage the child's medications or treatments?
How often do you coordinate medical appointments or therapies for the child?
How often do you assist with the child's daily personal care needs (e.g., bathing, feeding, mobility)?
How often do you advocate for the child's needs with schools, insurers, or other organizations?
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)
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
Please rank your top 3 care coordination challenges, from most to least challenging.
- 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
How easy is it to find clear information about the child's care plan and instructions?
How helpful has your child's healthcare team been as a source of support in the past 6 months?
How helpful have family and friends been as a source of support in the past 6 months?
How helpful have community or online support groups been in the past 6 months?
How helpful have care coordinators, case managers, or social workers been in the past 6 months?
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)
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?
How likely are you to recommend your child's primary healthcare provider to another caregiver in a similar situation?
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?
What is your age?
- 18–24
- 25–34
- 35–44
- 45–54
- 55–64
- 65 or older
- Prefer not to say
What is your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Which region do you live in?
- Africa
- Asia
- Europe
- North America
- South America
- Oceania
- Prefer not to say
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
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
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].
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.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Combines structured caregiver-strain and care-coordination scales (frequency of medication management, appointment coordination, advocacy, personal care assistance) with an AI follow-up interview that asks caregivers to describe the biggest gap in their support in their own words, adaptively probing for detail.
- Covers the full support ecosystem in one instrument — healthcare team, family/friends, community groups, and care coordinators/case managers are each rated separately, plus a ranked top-3 care coordination challenges question for prioritization.
- Includes outcome and system-level measures (satisfaction with care, feeling supported by the healthcare system, likelihood to recommend the provider) alongside caregiver demographics, so results can be segmented by relationship to child, health needs, and caregiving hours.
- Automated per-response quality scoring and an auto-generated report mean teams get a usable summary of caregiver strain and unmet needs without manually coding open-ended responses.
Jotform
100+ Caregiver FormsThis is a category/hub page listing a large library of caregiver-related forms rather than a single fielding-ready pediatric caregiver strain assessment. It's useful for finding intake, consent, or basic feedback forms, but a researcher would need to assemble and customize a specific instrument themselves. No dedicated template here targets caregiver strain, care coordination, or support-needs measurement for pediatric medical caregivers specifically.
What it does well
- Large selection of caregiver-related form templates covering many use cases
- Drag-and-drop form builder familiar to non-technical users
- Easy to customize static fields and branding
Where it falls short
- No adaptive AI interviewing or follow-up probing on open-ended responses — forms are static and collect the same fixed questions regardless of answers
- No built-in per-response quality scoring or automated analysis/report generation across the caregiver strain, coordination, and support domains
- As a form category page rather than a purpose-built assessment, it lacks a validated set of caregiver-strain and care-coordination scales ready to field
Frequently asked questions
What questions are in the “Pediatric Caregiver Experience & Support Needs Assessment” template?
The template includes 28 ready-to-use questions, starting with: “Are you an adult (18 or older) who currently serves as a primary caregiver for a child receiving medical care?” · “What is the age of the child you primarily care for?” · “What is your relationship to the child you primarily care for?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 28 questions in about 13 minutes.
Can I customize this template?
Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.
Is this template free to use?
Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.
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