Summer Programming for Maintaining Academic Stamina Question Title Consent Form OK Question Title * 1. How many school-age children do you have? OK Question Title * 2. Please specify your age range? Click the appropriate range below. Under 12 years old 12-17 years old 18-24 years old 25-34 years old 35-44 years old 45-54 years old 55-64 years old 65-74 years old 75 years or older OK Question Title * 3. Please specify your ethnicity. White Hispanic or Latino Black or African American Native American or American Indian Asian / Pacific Islander Other OK Question Title * 4. What is your marital status? Single, never married Married or domestic partnership Widowed Divorced Separated OK Question Title * 5. Employment Status: Are you currently…? Employed for wages Self-employed Out of work and looking for work Out of work but not currently looking for work A homemaker A student Military Retired Unable to work OK Question Title * 6. What is your total household income? Less than $25,000 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 to $149,999 $150,000 or more OK Question Title * 7. What is the highest degree or level of school you have completed? If currently enrolled, highest degree received. Some high school, no diploma High school graduate, diploma or the equivalent (for example: GED) Some college credit, no degree Trade/technical/vocational training Associate degree Bachelor’s degree Master’s degree Professional degree Doctorate degree OK Question Title * 8. Which region of the country do you live in? Midwest - IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD, WI Northeast - CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT Southeast - AL, AR, FL, GA, KY, LA, MS, NC, SC, TN, VA, WV Southwest - AZ, NM, OK, TX West - AK, CA, CO, HI, ID, MT, NV, OR, UT, WA, WY OK Question Title * 9. What is the age range of your child/children? Click all that apply. 3-5 6-8 9-11 12-14 15-18 OK Question Title * 10. From the drop-down menu, choose the time that most closely represents the time your child/children wake(s)-up during the school year. Earlier than 5am 5am-6am 6am-7am 7am-8am 8am-9am 9am-Later OK Question Title * 11. What is the grade level range of your child/children? Click all that apply. Pre-K Kindergarten – 1st Grade 2nd Grade – 3rd Grade 4th Grade – 5th Grade 6th Grade – 8th Grade 9th Grade – 12th Grade OK Question Title * 12. Does your child have daily chores that are required of him/her? Yes No OK Question Title * 13. Rate the level of your child/children’s academic stamina/productivity over the summer. *For each child Minimal Limited Average (Typically does something academic daily on Exceptional (Child doesn’t need any prompting to learn) OK Question Title * 14. From the drop-down menu, choose the time that most closely represents the time your child/children wake(s)-up in the summer. Earlier than 5am 5am-6am 6am-7am 7am-8am 8am-9am 9am-10am 10am-11am 11am-12pm 12 pm-later OK Question Title * 15. Would an in-home summer program be something you would be interested in? Yes No OK Question Title * 16. If you chose yes to the question above, would you prefer a complete in-home summer program (Entire 8-hour day planned) or a partial summer in-home program (Daily activities)? Complete Partial OK Question Title * 17. If you could choose how many hands-on academic activities your child could to do per day, how many are appropriate? 1 2 3 4 5 OK Question Title * 18. How much time per day do you think should be set aside for learning in the summer? Less than an hour 1-2 Hours 2-3 Hours 3-4 Hours 4-5 Hours 5-6 Hours 6-7 Hours 7-8 Hours More than 8 Hours OK Question Title * 19. During the summer, would you be willing to take field trips once per week or every other week with your children? Yes No OK Question Title * 20. How much money would you be willing to spend on a complete summer in-home program (Entire 8-hour day planned)? $25 $50 $75 $100 More than $100 OK Question Title * 21. How much money would you be willing to spend on a partial summer in home program (Daily activities)? $25 $50 $75 $100 More than $100 OK Question Title * 22. On average, how many minutes per day does your child read during the school year at home? Less than 10 minutes 10-20 minutes 20-30 minutes 30-40 minutes 40-50 minutes 50-60 minutes 60 or more minutes OK Question Title * 23. How many minutes per day does your child read during the summer at home? Less than 10 minutes 10-20 minutes 20-30 minutes 30-40 minutes 40-50 minutes 50-60 minutes 60 or more minutes OK Question Title * 24. On average, how many minutes daily does your child spend outside in the summer? Less than 30 minutes One hour Two hours Three hours Four hours or more OK Question Title * 25. What portion of the day are you and/or your partner at home during the summer? Day time Only Evening Only Both day time and evening Neither day time or evening OK Question Title * 26. During the summer, who is your child’s main caretaker? Parent/Guardian Grandparent Aunt/Uncle Babysitter/Nanny Other OK Question Title * 27. How often does your child complain of boredom in the summer? Not very often Sometimes Often Very often OK Question Title * 28. Does your child follow a schedule during the school year? Yes No OK Question Title * 29. Would you find a summer in-home program that could be easily implemented into your home beneficial? Yes No OK Question Title * 30. Rate the level of difficulty (1 being the least difficult and 5 being the most difficult) in identifying and/or implementing engaging academic related activities that are appropriate for your child during the summer. 1 (Easy) 2 (Moderate) 3 (Challenging) 4 (Difficult) 5 (Strenous) OK DONE