Thank you for taking time to print and complete this survey. Your input will assist the Siskiyou Local Child Care Planning Council in getting a better picture of families’ needs for child care and preschool in their community. All answers will be kept confidential. Please complete only one survey for your family. 
 

1.  Town of Residence _____________  Zip Code______________

2.  Which describes your family? (Please check all that apply)
___    2 parents/guardians (in house) 
___    1 parent/guardian (in home)
___    Extended family (grandparents or other relatives living in the home) Other:________________________

3.  Enter the number of people living in your household that you consider family in each age group listed below (include yourself).
___    adults (18 years and older, including parent/spouse/partner, grandparents, relatives living in the home, etc.)
___    children 13-17 years
___    children 9-12 years
___    children 5-8 years
___    children 2 years, 9 months  to 4 years, 11 months
___    children 15 months to 2 years, 8 months
___    children under 15 months
___    TOTAL number of people in the house

4.  Check which of the following applies to you.

5.  Describe your work status.  Check each that applies to you. 

6. Check the highest level of education for both you and your spouse/partner. (Please check only one box for you and one box for your partner.)

7.  What was your total household income last year before taxes?

___    below  $12,490  ___    $12,491 –  $15,670  ___    $15,671 –- $18,850 ___    $18,851 –  $22,030 ___    $22,031 –  $31,200

___    $31,201 - $35,100 ___    $ 35,101- $39,000 ___    $39,001 – $42,120 ___    $42, 121- $74,999 ___    $75,000  or  more

8. What language(s) are spoken in your home? (Please check all that apply.)

___    English  ___    American  ___    Sign Language  ___    Karuk

___    Spanish  ___    Laotian  ___    Other

9. What types of childcare or preschool do you currently have for your children?  List the type of care and age for each of your children.

Age	Hours  in Care	Months in Care	Location of Care	Type of Care
Example:      3	8 a.m. - 5 p.m.	year round	Weed	Child Care Center
.	.	.	.	.
.	.	.	.	.
.	.	.	.	.
.	.	.	.	.
.	.	.	.	.

10a.  Would you change your current child care or preschool arrangements if location, cost, time or transportation were not an issue?   ___ Yes     ___ No

10b. If yes, what would you like to change? 

11. Do you or your childcare provider have concerns about your child’s behavior?   ___ Yes     ___ No

12. Does the caregiver meet the needs of your child with challenging behaviors?   ___ Yes      ___ No
 Comment: _________________________________________________________________________________
__________________________________________________________________________________________

13. In the past 12 months, what were the three biggest problems in finding or using childcare or preschool? 
Please list the age of your children.

Age of Child ____ Identify the 3 biggest problems with finding childcare or preschool for each child.
1.
2.
3.
Age of Child ____ Identify the 3 biggest problems with finding childcare or preschool for each child.
1.
2.
3.
Age of Child ____ Identify the 3 biggest problems with finding childcare or preschool for each child.
1.
2.
3.

14.  How do you find out about children’s programs and childcare services? _______________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

15. How many times during the past year did your child care arrangements change? Please list changes in childcare for each child. 

16a. What is the total cost to you for child care for all of your children? ____________

16b.   What type(s) of payment assistance do you currently have? (For example:  childcare payment assistance, tribal assistance, relative, employer, etc.) ______________________________________________________________

16c. How many of your children does that include?    ______________________

17.  How does the cost of childcare affect your family situation?

18a. Are you aware of a family resource center in your community?    ___ Yes     ___ No

18b. Do you use it?     ___ Yes    ___ No

19. Would you like to participate in any of the following? (Please check all that apply).

20.  What services would you need to participate in these programs? Please check no more than 3.

___    Nothing  ___    Transportation  ___    Free or low-cost babysitting  ___    Assistance in locating a babysitter  ___    Programs located within my community  ___    Accommodations for my disability            ___________________________________ _____________________________________________

___    Free or low-cost programming ___    Posting of notice of events in my local newspaper ___    Posting of events at my child’s school or            child care program ___    Posting of events on internet ___    Other:  __________________________________

21.   Additional comments and concerns: ___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________