What Connects Us ~ Ce Qui Nous Lie : Survey 2c

If you would like someone to fill this form out together with you, please call (514) 398 4400 – (09670) and leave a message with a phone number and the best time to contact you, and a research team member will call you back within 24 hours of receiving the message.

1. Please enter your postal code:

2. Please enter the Canadian province or Country where you mostly live:

3. Age

4. Please check all that apply. Do you self-identify as :

Female

Male

Other (please specify if you would like)

5. Do you identify as a newcomer to Canada? (How long you and your family have been here)

I moved to Canada

My parent(s) moved to Canada

My grandparent(s) moved to Canada

Too many generations to remember

I am indigenous

Other (please specify where you are living outside of Canada)

6. We have been asked by the Public Health Agency of Canada to track the reach and impact of our initiative, can you please check as many as apply. I self-identify as,

Person.s living with a mental illness

Person.s living with Alzheimer's and other related disorders

Person.s who has a disability

Person.s who is Black

Person.s who is Indigenous

Person.s of colour

Person.s who is part of the 2SLGBTQQIPAA community

Carer.s for a person living with a mental illness

Carer.s for a person living with Alzheimer's and other related disorders

2. Do you self-identify as a person living with neurocognitive challenges?

Yes

4.Do you self-identify as caregiving for a person living with neurocognitive challenges?

*caring – providing paid or unpaid care to support a family member, partner, or friend with neurocognitive challenges.

Yes

5. Do you self-identify as indigenous?

Yes

6.Do you self-identify as having a disability?

Yes

8. Do you self-identify as being a part of the LGBTQ+ community?

Yes

9. In which What connects us-Ce qui nous lie Partner(s) activity and/or activities (e.g., film screening, art-therapy, laughter yoga, on-line art links, etc.) do you or will you participate? Please write in the activities below. Please click on the [+] if you need more than three activities

9. In which What connects us-Ce qui nous lie Partner(s) activity and/or activities (e.g., film screening, art-therapy, laughter yoga, on-line art links, etc.) do you or will you participate? Please write in the activities below. Please click on the [+] if you need more than three activities
	9. In which What connects us-Ce qui nous lie Partner(s) activity and/or activities (e.g., film screening, art-therapy, laughter yoga, on-line art links, etc.) do you or will you participate? Please write in the activities below. Please click on the [+] if you need more than three activities	Item weight
	9. In which What connects us-Ce qui nous lie Partner(s) activity and/or activities (e.g., film screening, art-therapy, laughter yoga, on-line art links, etc.) do you or will you participate? Please write in the activities below. Please click on the [+] if you need more than three activities	Item weight
	9. In which What connects us-Ce qui nous lie Partner(s) activity and/or activities (e.g., film screening, art-therapy, laughter yoga, on-line art links, etc.) do you or will you participate? Please write in the activities below. Please click on the [+] if you need more than three activities	Item weight

Other activities: Please click [Add] if you need more than one row

Other activities: Please click [Add] if you need more than one row
Other activities: Please click [Add] if you need more than one row

8. In order to adapt our activities to comply with social-distancing measures, we will be connecting to individuals in the community via online platforms. Let us know the extent to which you agree or disagree with the following 2 statements:

Questions	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1. Older adults are able to use technology to stay connected (e.g., computers, ipads, Skype, Zoom, etc…)	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
2. Older adults are not able to learn how to use technology to stay connected (e.g., computers, ipads, Skype, Zoom, etc…)	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree

9. In your opinion, what would be the biggest barrier in technology adoption by older adults?

11. The following are health-related quality of life questions:

a) In general, would you say that your health is:

Excellent

Very Good

Good

Fair

Poor

Very poor

b) This next question is about your physical health, it can include any physical illness or injury that you might have experienced in the past 30 days

How many days during this period, would you say your physical health was not good?

c) Now think about your mental health, it can include depression, stress and problems with emotions that you might have experienced in the past 30 days

How many days during this period, would you say your mental health was not good?

d) Now, think about your daily activities, it can include self-care, work or recreation. Again, please focus on the past 30 days.

How many days during this period, would you say you have difficulties performing your usual activities due to your physical or mental health?

12. In the last month, how often do you ...

Questions	Never	Rarely	Sometimes	Often
Lacked companionship	Never	Rarely	Sometimes	Often
There is no one I can turn to	Never	Rarely	Sometimes	Often
I am an outgoing person	Never	Rarely	Sometimes	Often
I feel left out	Never	Rarely	Sometimes	Often
I feel isolated from others	Never	Rarely	Sometimes	Often
I can find companionship when I want it	Never	Rarely	Sometimes	Often
I am unhappy being so withdrawn	Never	Rarely	Sometimes	Often
People are around me but not with me	Never	Rarely	Sometimes	Often
Do you feel lonely ?	Never	Rarely	Sometimes	Often

13. Do you know anyone else who would like to participate in the what connects us~ce qui nous lie project?

Yes

If you would like a record of your answers, please send us an email at info@whatconnectsus-cequinouslie.org with the title of your survey and date you completed it.

We thank you for your time and engagement with helping us build an interconnected community for persons living with Alzheimer's and/or other related disorders and their carers.

If you would like to hear about other ways in which you can participate in research and help develop activities and become a member of What connects us-Ce qui nous lie please go to our website, https://whatconnectsus-cequinouslie.org/

If you would like a list of mental health resources, please request for the Community Care Networks; Telehealth intervention to reduce isolation of older adults (TIP-OA) or Warm lines from the ‘’Little Brothers’’ Association.

If you attended Time, Family, and Conversations about Neurodiversity and would like a copy of the wooclap word cloud, please enter your email below.

I would be willing to be contacted again for other research activities related to whatconnectsus-cequinouslie.org?

Please enter your email or phone number here and a research team member will get back to you soon.

Email:

Phone number:

If you would like to be contacted for any interviews, please send us an e-mail at: info@whatconnectsus-cequinouslie.org