leisure, community, study, or employment activities limited due to any of the following? No Yes About You Calls more than once a week for 1 you to help with the care Your Centrelink Reference Number (CRN) person’s at day activity, work placement or other regular programs 2 Your Date of Birth You have to stay while the person / / attends a weekly activity due to their care needs 3 The person you care for is unable to Where you live attend programs or organised Please tick one activities due to their care needs In a metropolitan area (i.e. within 30 kms of a Restriction on the hours the capital city) person can attend programs In a regional (e.g. day activity, post-school options or supported employment) due to the area In a severity of their condition remote area Having to attend appointments with the person more than once a 4 Your fortnight gender Providing emergency care and Male support to the person Female Sleep disruption for you on most nights due to the person’s 5 Is English the main language you use time care needs or behaviours because of their disability or at home? No medical condition Yes About the person who is receiving care 6 Are you an Aboriginal or Torres Strait Islander person? No Centrelink Reference Number (CRN) of the person who is receiving care Yes (if known) Is your ability to participate in 11 Do you consent to us contacting you about this field test? Date of birth of the person who is receiving care Go to next question Please provide your phone 12 Gender of the person who is number below receiving care Male / / Would you like information on other carer support 13 What is your relationship to the person services? receiving care (e.g. parent, child, grandparent, friend)? Female Go to next question I provide this care in this home (i.e. in a Please use my phone person’s private home that is the residence of the carer or number provided above the person receiving care) OR No Yes
About You 1 Your Centrelink Reference Number (CRN) 2 Your Date of Birth / / 3 Where you live Please tick one In a metropolitan area (i.e. within 30 kms of a capital city) In a regional area In a remote area 4 Your gender Male Female 5 Is English the main language you use at home? No Yes 6 Are you an Aboriginal or Torres Strait Islander person? No Yes Is your ability to participate in leisure, community, study, or employment activities limited due to any of the following? No Yes Calls more than once a week for you to help with the person’s care at day activity, work placement or other regular programs You have to stay while the person attends a weekly activity due to their care needs The person you care for is unable to attend programs or organised activities due to their care needs Restriction on the hours the person can attend programs (e.g. day activity, post-school options or supported employment) due to the severity of their condition Having to attend appointments with the person more than once a fortnight Providing emergency care and support to the person Sleep disruption for you on most nights due to the person’s care needs or behaviours because of their disability or medical condition About the person who is receiving care Centrelink Reference Number (CRN) of the person who is receiving care (if known) Do you consent to us contacting you about this field test? 11 Date of birth of the person who is receiving care Go to next question Please provide your phone number below / / 12 Gender of the person who is receiving care Male Would you like information on other carer support services? Female 13 What is your relationship to the person receiving care (e.g. parent, child, grandparent, friend)? Go to next question Please use my phone number provided above OR I provide this care in this person’s home (i.e. in a private home that is the residence of the carer or the person receiving care) No Yes time
adult_carer_report_0.docx