C-CART Assessment Tool - Demographics

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Demographics

Please tell us about the person you are caring for so that we can suggest the most appropriate resources. This information will also be used to refine and improve the C-CART experience.

What is the age of the person you care for? What is your relationship with the person you care for? What setting does the person you care for live in? Which province/territory does the person you care for live in? Does the person you care for live in a rural or urban area? Is the person you are caring for a veteran?

Yes No

Does the person you care for identify as an Indigenous Person in Canada, such as First Nation, Métis, or Inuit?

Yes No

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Knowledge of Individual’s Condition What is the condition of the person you care for? (Check all that apply)

ALS (Amyotrophic Lateral Sclerosis)
Addiction/Substance
Anxiety
Autism Spectrum
Bipolar
Brain Injury (TBI, Aneurysm)
Cancer
Cerebral Palsy
COPD (Chronic Obstructive Pulmonary Disease)
Cystic Fibrosis
Depression
Dementia (Including: Alzheimer's, Frontotemporal, Vascular Dementia, Dementia with Lewy Body, Korsakoff)
Diabetes
Down Syndrome
Eating Disorders
FASD (Fetal Alcohol Spectrum Disorder)
Fibromyalgia
General Developmental Disability
Heart Disease
Hearing Loss
Long Covid
MCI (Mild Cognitive Impairment)
MS (Multiple Sclerosis)
Mobility Issues/Fall Risks
Muscular Dystrophy
Neurodivergence
Parkinson’s
PTSD (Post-Traumatic Stress Disorder)
Schizophrenia
Sickle Cell Anemia
Stroke
Vision Loss
Unknown

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Additional Care Considerations Would you like to find out more information about any of the following (check all that apply)?

Home renovations/modifications for accessibility purposes
Advance care planning
Transitioning into a different living situation/setting
Applying to Long-Term Care
In-home support services such as Personal Support Workers (PSWs)
Respite care
Capacity and guardianship
Alternative schooling
Housing
Tutoring
Access to food
Caregiver support groups
Finding a physician/nurse practicioner
Other

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General Assessment & Resource Knowledge Please select all that apply: What are some barriers you encounter in your caregiving experience?
Unsure where to find professional help
Financial reasons (e.g., expensive assistance, limited resources, unable to afford)
Family reasons (e.g., family members unavailable to support or contribute)
Professional help is not available
Reasons related to eligibility for services, health system, or waitlists, flexibility hours/times
Do not qualify for services due to age or geographical area
Long waitlist
Personal physical health
Personal mental health
Unsure of what services are available
Not enough time
Services are not provided in my language
Services are not culturally sensitive
Difficulty with technology

Please select all that apply: Where do you go when you have a question/concern related to the condition of the person you care for?
Family Doctor
Counsellor
Religious/Spiritual Group
Pharmacist
Healthcare Team
Agency/Organization
Friend/Peer/Colleague
Internet
Social Media
Family
Other

How often do you engage in self-care activities?

Self-care means engaging in physical activities such as exercising or eating healthy, enjoying mental activities such as reading, journaling, or taking part in social or spiritual activities including meditation, visiting friends, or any other activities that help reduce stress in your life.

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Mood

Caregivers often experience prolonged stress which can have an impact on their mood.

In the following question, please check off the number of days over the last two weeks that you have been impacted by any of the following:

i. Little interest or pleasure in doing things

Not at all Several days More than half the days Nearly every day

ii. Feeling down, depressed, or hopeless

Not at all Several days More than half the days Nearly every day

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Finance How often do you have financial concerns about covering your basic necessities?

Do your caregiving responsibilities negatively affect your employment or lead to changes in your work/school situation?

Yes No

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Caregiver Demographics

The following set of questions will help us better understand the Canadian caregiver population and assist us in improving the C-CART experience.

What is your age (the caregiver)?
Which province/territory do you live in? Do you live in a rural or urban area?
Do you identify as an Indigenous Person in Canada, such as First Nation, Métis, or Inuit? Yes No
Select the population group(s) you identify with

Arab
Black
Caucasian
Chinese
Filipino
Japanese
Korean
Latin American
South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.)
Southeast Asian (e.g., Vietnamese, Cambodian, Laotian, Thai, etc.)
West Asian (e.g., Iranian, Afghan, etc.)
Prefer not to answer
Population group not listed above.

Which of the following describes your current gender identity? (check all that apply)

Agender
Bigender/Multigender
Gender Fluid
Genderqueer
Man
Nonbinary
Questioning
Transgender
Two-Spirit
Woman
A gender not specified above
Prefer not to answer

What is your employment status (check all that apply)?

Student
Employed
Not employed
Retired
Other

Please ensure to complete all questions section before submitting.

Thank you for completing the Canadian Caregiver Assessment and Resources Tool (C-CART). On the next page you will receive your personalized resources. Please click ‘Continue to Resources’ to view.
You are encouraged to save these resources for future reference.

Canadian-Caregiver Assessment Resource Tool (C-CART)

The Canadian-Caregiver Assessment and Resources Tool