Caregiving Self-Efficacy Survey "*" indicates required fields Step 1 of 5 20% Today's Date * Required(MM/DD/YYYY) MM slash DD slash YYYY Birthday * Required(MM/DD/YYYY) MM slash DD slash YYYY Name * Required First Last Instructions: We are interested in how confident you are that you can keep up your own activities and also respond to caregiving situations. Please think about the questions carefully and be as frank and honest as you can about what you really think you can do. These items cover activities and thoughts that could come up for you as a caregiver. Please think about each one and tell how confident you are that you could do each item. Rate your degree of confidence using the response scale from 0 (Cannot do at all) to 100 (Certain can do). PLEASE USE ONLY WHOLE NUMBERS IN YOUR RESPONSES. Self-Efficacy for Obtaining Respite (X represents your family member, care recipient, loved one, etc.) How confident are you that you can ask a friend/family member to stay with "X" for a day when you need to see the doctor yourself? * RequiredPlease enter a number from 0 to 100.How confident are you that you can ask a friend/family member to stay with "X" for a day when you have errands to be done? * RequiredPlease enter a number from 0 to 100.How confident are you that you can ask a friend/family member to do errands for you? * RequiredPlease enter a number from 0 to 100.How confident are you that you can ask a friend/family member to stay with "X" for a day when you feel the need for a break? * RequiredPlease enter a number from 0 to 100.How confident are you that you can ask a friend/family member to stay with "X" for a day when you need the time for yourself? * RequiredPlease enter a number from 0 to 100. Self-Efficacy for Responding to Disruptive Behaviors (X represents your family member, care recipient, loved one, etc.) How confident are you that, when "X" forgets your daily routine and asks when lunch is, right after you've eaten, you can answer "X" without raising your voice? * RequiredPlease enter a number from 0 to 100.How confident are you that, when you get angry because "X" repeats the same question over and over, you can say things to yourself that calm you down? * RequiredPlease enter a number from 0 to 100.How confident are you that, when "X" complains to you about how you're treating him/her, you can respond without arguing back? * RequiredPlease enter a number from 0 to 100.How confident are you that, when "X" asks you 4 times in the first one hour after lunch when lunch is, you can answer him/her without raising your voice? * RequiredPlease enter a number from 0 to 100.How confident are you that, when "X" interrupts you for the fourth time while you're making dinner, you can respond without raising your voice? * RequiredPlease enter a number from 0 to 100. Self-Efficacy for Controlling Upsetting Thoughts about Caregiving (X represents your family member, care recipient, loved one, etc.) If applicable, enter 0-100 in box for Other How confident are you that you can control thinking about unpleasant aspects of taking care of "X"? Not applicable (never had these thoughts) Other How confident are you that you can control thinking how unfair it is that you have to put up with this situation? Not applicable (never had these thoughts) Other How confident are you that you can control thinking about what a good life you had before "X's" illness and how much you've lost? Not applicable (never had these thoughts) Other How confident are you that you can control thinking about what you are missing or giving up because of "X"? Not applicable (never had these thoughts) Other How confident are you that you can control worrying about future problems that might come up with "X"? Not applicable (never had these thoughts) Other How has participating in a support group positively impacted your life?
