Family Survey
Thank you for taking time
to complete this survey. Your input
will assist your First Steps County Partnership in getting a better picture of families’ needs for early education
and care in their community. Answering
any of the questions is optional and all answers will be kept confidential.
Please complete only one survey for your family.
Please Note: The term “early education and care” is
meant to include all types of care for your children, including: family child
care, center-based care, Head Start, preschool, nursery school, public school,
kindergarten, school-age care, babysitters, relative care, nannies, and
parental care.
1. City of Residence: ____________________ Zip Code: __________
2. Which describes your family? (Please
check all that apply.)
q 2-parents/guardians (in home) q 1 parent/guardian (in home)
q Extended Family (grandparents or other relatives
living in the home)
q Other:_____________________________________
3. Please
enter the number (#) of people living in your household that you consider
family in each age group listed below (include
yourself).
____
# of Adults (18 years and older, including parent/spouse/partner,
grandparents, relatives living
in the home, etc.)
____
# of children 13-17 years.
____
# of children 9-12 years.
____
# of children 5-8 years.
____
# of children 3 years - 4 years, 11 months.
____
# of children 12 months - 2 years, 11 months.
____
# of children under 12 months.
____
Add the numbers above to get the TOTAL
number of people in the home.
ADULT INFORMATION
4. Please
describe the current work status as of January 15, 2003 of the adults in your
household.
Place a check mark in each of the boxes
that applies to you and other adults in your household.
|
Occupation |
Yourself |
Spouse/ Partner |
Other
Adult: __________ |
|
Employed 30 hours or more per week |
|||
|
Employed fewer than 30 hours per week |
q
|
q
|
q
|
|
Full-time parent (does not work outside the home
for wages) |
q
|
q
|
q
|
|
Student/training program |
q
|
q
|
q
|
|
Not employed |
q
|
q
|
q
|
|
Other: _______________ |
q
|
q
|
q
|
5. Check the highest level of education for both you
and your spouse or partner.
(Please check only one box for you, and one
box for your spouse/partner.)
|
Education |
You |
Spouse/Partner |
|
No high school diploma or GED |
q |
q |
|
High school diploma or GED |
q |
q |
|
Some college |
q |
q |
|
Associate’s Degree |
q |
q |
|
Bachelor’s Degree |
q |
q |
|
Graduate degree |
q |
q |
|
Other:_____________________ |
q |
q |
6.
What was your total household income last year
(before taxes)?
(Please
check only ONE category.)
|
q Below
$5,000 |
q $35,000 -
$49,999 |
|
q $5,000 -
$9,999 |
q $50,000 –
$74,999 |
|
q $10,000 –
$14,999 |
q $75,000 –
$99,999 |
|
q $15,000 –
$24,999 |
q $100,000 -
$149,000 |
|
q $25,000 -
$34,999 |
q $150,000 or more |
7. What
language(s) are spoken in your home? (Please
check all that apply.)
q English q Spanish
q Other (please
specify)______________________________________
8.
What types of care do you currently have for your children? Please answer for only your youngest three
children and indicate the children’s ages. Check the boxes that describe the
type of care.
|
|
Child 1 Age: ___ yrs.
___ mos. |
Child 2 Age: ___ yrs.
___ mos. |
Child 3 Age: ___ yrs.
___ mos. |
|||
|
TYPE OF CARE (Check all that apply) |
Check Type of
Care |
Check Type of Care |
Check Type of Care |
|||
|
Parent/Guardian
at home with child(ren) |
q
|
q
|
q
|
|||
|
Family
member, neighbor or friend in our
home |
q
|
q
|
q
|
|||
|
Family
member, neighbor or friend in their
home |
q
|
q
|
q
|
|||
|
Family
child care/ Home-based care |
q
|
q
|
q
|
|||
|
Child
care center or Nursery school or Private preschool |
q
|
q
|
q
|
|||
|
Head
Start |
q
|
q
|
q
|
|||
|
Public
school preschool |
q
|
q
|
q
|
|||
|
Public
school kindergarten |
q
|
q
|
q
|
|||
|
Private
kindergarten |
q
|
q
|
q
|
|||
|
Public
school (1st grade and
above) |
q
|
q
|
q
|
|||
|
Private
school (1st grade and above) |
q
|
q
|
q
|
|||
|
Drop-in
after school program |
q
|
q
|
q
|
|||
|
School-based
after-school program and/or before-school program |
q
|
q
|
q
|
|||
|
Community-based
after-school program and/or before-school program |
q
|
q
|
q
|
|||
|
Other: _______________________________ |
q
|
q
|
q
|
9. A. Would you change your current child care arrangements if cost, time, or
transportation
were not an issue? q Yes q No
B.
IF YES, what would you like
to change? (CHECK ALL THAT APPLY.)
q
Type of arrangement (e.g., from a family member to a preschool program)
q Quality of
program/provider - place my child in a better setting.
q Location
__ Closer to home?
__ Closer to work?
__ Other location? Please specify:
________________________
q
Hours per day
__ More hours?
How many more? ____
__
Less hours? How many less? ____
q Days per week
__ More? __ Less?
q Other
change: specify
_______________________________________________
10. Do you have a child with a disability?
q No. Go to Question 11.
q Yes. What is the disability? ___________________________________________
10b. Does the caregiver meet the needs of your
child with a disability?
Child #1: q Never q Sometimes q Often q Always
Child #2: q Never q Sometimes q Often q Always
Child #3: q Never q Sometimes q Often q Always
11.
In the past 12 months what were the three biggest problems in finding or
using early care and education?
Please answer only for
your youngest children and check no more
than 3 per child.
Infant/Toddler
|
q |
Cost |
q |
Transportation |
q |
Location of services |
q |
Trust of Staff |
q |
Hours of care |
|
q |
Lack of Services for children with special needs |
q |
Philosophy/ Program Orientation |
q |
Could not find program openings or long wait lists |
q |
Other: __________ |
q |
I
have not had any
problems |
Preschooler
|
q |
Cost |
q |
Transportation |
q |
Location of services |
q |
Trust of Staff |
q |
Hours of care |
|
q |
Lack of Services for children with special needs |
q |
Philosophy/ Program Orientation |
q |
Could not find program openings or long wait lists |
q |
Other: __________ |
q |
I
have not had any
problems |
School age child
|
q |
Cost |
q |
Transportation |
q |
Location of services |
q |
Trust of Staff |
q |
Hours of care |
|
q |
Lack of services for children with special needs |
q |
Philosophy/ Program Orientation |
q |
Could not find program openings or long wait lists |
q |
Other: __________ |
q |
I
have not had any
problems |
12. How did/do you find out about early
education and care services?
(Please check all that apply.)
|
q Doctor,
Nurse, or other Medical Personnel q Child
Care Provider q Family
or Friends with Children q
Internet q
Resource and Referral Agency q
Community Service Agency q Town
Library q
Department of Social Services q WIC
Services |
q Pamphlet,
Posters or Brochure q Public
Preschool Screening q
Telephone Inquiry; Yellow Pages q Public
School q TV,
Radio, Newspaper, or Magazine q First
Steps q State
Agency q Other
(please describe): __________________________ |