Workplace Wellness Survey What is today's date? * Required(MM/DD/YYYY) MM slash DD slash YYYY Do you have persons (e.g., parent, grandparent, etc.) for whom you ARE PROVIDING regular monitoring and care? * Required(Daily or weekly well-being checks) Yes No Unsure What is YOUR age range? 50 or older 40 to 49 30 to 39 20 to 29 How long have you provided regular monitoring and care for this person? * Required Less than a year 1 to 3 years More than 3 years What is the age range of THE PERSON YOU ARE CARING FOR? 80 or older 70 to 79 60 to 69 50 to 59 Has your monitoring or care of this person impacted your work life?.(Check all that apply) Absence from work (arrive late, leave early, take unplanned leave) Accepting or rejecting role changes at work Negative work performance warnings Considering early retirement or resignation None of these Do you have persons in your life for whom you WOULD BE WILLING TO PROVIDE regular monitoring and care if asked? * Required(Daily or weekly well-being checks) Yes No Unsure How would you rate your employer's (e.g., UAMS) commitment to providing you a work-life balance? * Required Very committed Somewhat committed Slightly committed Uninterested I don’t know Programs and Services that would be of interest to you as a caregiver. Exercise Programs Individual and Family Support Services Financial/Legal/Medicare Advising Caregiver Education Nutrition Education Dementia Education Please list any services or programs that are not listed above that would be of interest to you as a caregiver.Please name or describe any program that your employer (e.g., UAMS) provides that are helpful to you in creating a work-life balance.Would you like to be kept informed about this project? * Required Yes No Email * Required(Your email will be added to group responses; no individual communications.)
