[Template - Insert service name]

COGNITIVE IMPAIRMENTSURVEY

The following survey deals with cognitive impairment and how this interacts with service provision at [insert service name].You will be asked questions on cognitive impairment, the way it is experienced by individuals, the prevalence of cognitive impairment inclients[insert service name]and the strategies that are currently utilised by staff when cognitive impairment is identified.

This survey contains a mixture of questions, some which require you to tick the box which you consider to be the most appropriate answer and others that require a short written answer. Please do not guess, if you do not know the answer please tick the box which indicates this, and please be careful to mark you answer clearly. This survey forms part of an initiative to improve service provision at [insert service name]for individuals with cognitive impairment, and the information you provide is valuable in working towards achieving this.

Date:

  1. Which[insert service name] program do you work in?[delete/add as required]

<Insert list of programs within your service>

  1. What is your main role/s in client/resident treatment or service provision?[delete/add in as required]

AdministrationGroups/education

AssessmentResidential Care Worker

Medical CareResearch/management

CounsellingOther, please specify below

  1. What are the common causes of cognitive impairment?
  1. Cognitive impairment affects each individual in the same way, true or false?

TrueFalse I don’t know

  1. Indicators of cognitive impairment are easily identifiable.

 Agree Disagree I don’t know

  1. In which of the following areas of functioning could an individual with cognitive impairment experience indicators/symptoms?

 Emotional Physical Cognitive & Physical

All of the above I don’t know

  1. People with acquired brain injury experience cognitive impairment. Which of the following would be the closest approximation of the prevalence of acquired brain injury, with activity limitations or participation restrictions due to disability, in Australia?

 1 in 45 Australians 1 in 80 Australians

 1 in 100 Australians 1 in 235 Australians

 I don’t know

  1. Which of the following is the highest prevalence group for acquired brain injury as their main health condition?

 Females 15- 34 years Males 15- 34 years

 Females 35 years and over Males 35 years and over

 I don’t know

  1. People with alcohol related brain damage experience cognitive impairment. Which of the following would be the closest approximation of the number of people in Australia who are drinking at levels which place them at risk of cognitive impairment resulting from alcohol related brain damage?

 1 in 36 1 in 24 1 in 16 1 in 8 I don’t know

  1. Consumed over an 8-10 year period, which level of drinking places an individual at risk of cognitive impairment resulting from alcohol related brain damage?

MEN WOMEN

 2-3 standard drinks/day 3-4 standard drinks/day

 4-5 standard drinks/day 5-6 standard drinks/day

 6-8 standard drinks/day Over 6 standard drinks/day

 Over 8 standard drinks/day I don’t know

 I don’t know

  1. Which of the following would be the closest approximation of head injuries which are associated with alcohol abuse?

 25% 30% 50% 65% I don’t know

  1. Fetal Alcohol Spectrum Disorder(FASD) is a general term describing the range of effects, including cognitive impairment that can occur in an individual whose mother consumed alcohol during pregnancy. List three ways FASD can effect cognitive functioning.
  1. People with an intellectual disability experience cognitive impairment. If people with an intellectual disability use alcohol they are more likely to develop ‘problem’ use as compared to the general population, True or False?

 True False I don’t know

  1. List 6 indicators/symptoms that could be experienced by an individual with cognitive impairment.
  1. In the last 12 months, how many clients/ residents have you identified as having indicators of cognitive impairment?
  1. If you have identified indicators of cognitive impairment in clients/ residents, list the indicator/s identified and provide a brief description of the strategies you used to address these in treatment/service provision. If you require more space to write you response please use the back of this page.

Thank you!

[Insert organisation name] Cognitive Impairment Survey– [Insert month/year]