Elderly Care Research Recruitment Screener
Full Name
Age
Email Address
Phone Number
Are you currently a caregiver for an elderly individual?
Yes
No
Relationship to the elderly individual (if applicable)
Family
Friend
Professional caregiver
Other
What best describes your current living arrangement?
Live with elderly individual
Visit regularly
Live separately
Other
Which of the following care tasks do you assist with? (Select all that apply)
Medication Management
Mobility Assistance
Personal Hygiene
Meal Preparation
Household Tasks
Other
Are you available for a research interview?
Yes
No
Additional Comments