Caregiver Burden Form and Dictionary
| Caregiver Burden Form | ||
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| Variable / Field Name | Field Label | Choices, Calculations, OR Slider Labels |
|---|---|---|
| caregiver_burden_adcid | Site: 39 ADCID | caregiver_burden_ptid | Subject ID: PTID | caregiver_visitdate | Form Date: (Y-M-D) | caregiver_burden_visitnum | Visit number: 1 (Initial visit), 2 and up (Follow up visit) VISITNUM | caregiver_burden_initials | Caregiver's initials: INITIALS | caregiver_burden_visitdate | Data Entry Date: (Y-M-D) | caregiver_burden_entry_by | Data Entry By | caregiver_admin_st | Administered Status | 1, 1 Yes | 95, 95 - No, Physical problem | 96, 96 - No, Cognitive/behavior problem | 97, 97 - No, Other problem | 98, 98 - No, Verbal refusal | 99, 99 - Not Administered | caregiver_burden_text_00 | Form A: to be completed by the caregiver ZARIT BURDEN INTERVIEW Indicate how often you experience the feelings listed by circling the number in the box that best corresponds to the frequency of these feelings | caregiver_burden_q1 | 1. Do you feel that because of the time you spend with your relative that you don't have enough time for yourself? | 0, 0 Never | 1, 1 Rarely | 2, 2 Sometimes | 3, 3 Quite Frequently | 4, 4 Nearly Always | caregiver_burden_q2 | 2. Do you feel stressed between caring for your relative and trying to meet other responsibilities (work/family)? | 0, 0 Never | 1, 1 Rarely | 2, 2 Sometimes | 3, 3 Quite Frequently | 4, 4 Nearly Always | caregiver_burden_q3 | 3. Do you feel angry when you are around the relative? | 0, 0 Never | 1, 1 Rarely | 2, 2 Sometimes | 3, 3 Quite Frequently | 4, 4 Nearly Always | caregiver_burden_q4 | 4. Do you feel that your relative currently affects your relationship with family member or friends in a negative way? | 0, 0 Never | 1, 1 Rarely | 2, 2 Sometimes | 3, 3 Quite Frequently | 4, 4 Nearly Always | caregiver_burden_q5 | 5. Do you feel strained when you are around your relative? | 0, 0 Never | 1, 1 Rarely | 2, 2 Sometimes | 3, 3 Quite Frequently | 4, 4 Nearly Always | caregiver_burden_q6 | 6. Do you feel that your health has suffered because of your involvement with your relative? | 0, 0 Never | 1, 1 Rarely | 2, 2 Sometimes | 3, 3 Quite Frequently | 4, 4 Nearly Always | caregiver_burden_q7 | 7. Do you feel that you don't have has much privacy as you would like because of your relative? | 0, 0 Never | 1, 1 Rarely | 2, 2 Sometimes | 3, 3 Quite Frequently | 4, 4 Nearly Always | caregiver_burden_q8 | 8. Do you feel that your social life has suffered because you are caring for your relative? | 0, 0 Never | 1, 1 Rarely | 2, 2 Sometimes | 3, 3 Quite Frequently | 4, 4 Nearly Always | caregiver_burden_q9 | 9. Do you feel that you have lost control of your life since your relative's illness? | 0, 0 Never | 1, 1 Rarely | 2, 2 Sometimes | 3, 3 Quite Frequently | 4, 4 Nearly Always | caregiver_burden_q10 | 10. Do you feel uncertain about what to do about your relative? | 0, 0 Never | 1, 1 Rarely | 2, 2 Sometimes | 3, 3 Quite Frequently | 4, 4 Nearly Always | caregiver_burden_q11 | 11. Do you feel you should be doing more for your relative? | 0, 0 Never | 1, 1 Rarely | 2, 2 Sometimes | 3, 3 Quite Frequently | 4, 4 Nearly Always | caregiver_burden_q12 | 12. Do you feel you could do a better job in caring for your relative? | 0, 0 Never | 1, 1 Rarely | 2, 2 Sometimes | 3, 3 Quite Frequently | 4, 4 Nearly Always | caregiver_burden_tot0 | Total for column 0 | caregiver_burden_tot1 | Total for column 1 | caregiver_burden_tot2 | Total for column 2 | caregiver_burden_tot3 | Total for column 3 | caregiver_burden_tot4 | Total for column 4 | caregiver_burden_tots | Total Score |