SISKIYOU COUNTY
CHILD CARE AND PRESCHOOL SURVEY FOR PARENTS

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.

___     White 
___     Asian
___     Latino/Hispanic/Spanish 
___     African American
___     Native American 
___     Other______________

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

Work Status
Yourself
Spouse/Partner 
Other Caregiver
Employed 30 hours or more per week  . . .
Employed fewer than 30 hours per week . . .
Full-time parent (does not work outside the home for wages)  . . .
Student/training program  . . .
Not employed  . . .
Other . . .

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.)

Education
Yourself
Spouse/Partner
No high school diploma or GED  . .
High school diploma or GED . .
Some college . .
Associate’s Degree  . .
Bachelor’s Degree . .
Graduate Degree  . .
Other  . .

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? 

___    Type of Arrangement (for example:  from a family member to a preschool program) 
From______________________________________     To________________________________________
___    Quality of program/provider (place my child in a better setting)
___    Location: 
___  Closer to home
___  Closer to work
___  Other location (please specify) _____________________________________________
___    Hours per day: 
___  More hours-How many more? 
___  Less hours-How many less? 
___    Days per week:  ___ More   ___ Less
___    Other: 

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. 

Age of Child
Number of Times Child Care Changed in One Year
Reason for Change
. . .
. . .
. . .
. . .
. . .

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?

___    No impact 
___    Have unpaid bills
___    Unable to save money 
___    Went into debt
___    Have bare minimum for living expenses 
___    Used up savings
___    Unable to afford necessities 
___    Lost or quit job
___    Borrowed money 
___    Other:

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).

Activity
Yes, I would participate
Best Time is
Weekday Morning
Best Time is
Weekday Evening
Best Time is
Weekends
Best Time
is Other
Parent Education . . . . .
Parent/Child Events . . . . .
Play Groups . . . . .
Home Visits . . . . .
Literacy Activities . . . . .
Other . . . . .

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: ___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
 

MAIL TO OR DROP OFF AT
DROP OFF AT ANY FAMILY RESOURCE CENTER
FOR QUESTIONS OR COMMENTS
Siskiyou County 
Local Child Care Planning Council
C/O Weed Elementary
575 White Avenue
Weed CA 96094 
Dunsmuir – Kids Factory 235-4005
Tulelake  667-2147 
Dorris  397-3659 
Mt. Shasta  926-1436
McCloud  964-3250
Yreka–Choices for Children 842-1313
Fort Jones-Scott Valley FRC 468-2450
Happy Camp FRC 493-5117
Montague HUB – Library 459-3481 
Call Emily Lacroix at 938-6103
elacroix@sisnet.ssku.k12.ca.us