1. Welcome to the My Little Waiting Room Need Survey!

Thank you for visiting and taking the time to comment on your need for on-site drop-in childcare at a medical center or hospital! All of these questions are optional, please feel free to answer only those questions that you are comfortable answering. This information will be used for research purposes and to aid our organization in securing support for our concept. We will not sell your information.

We would like to thank the Avon Hello Tomorrow Fund for being the first organization to believe in and support our concept! We would also like to thank Bright Starts and their Kids II Foundation for their leadership support and wonderful Pink Power Mom program. For more information about the good work Bright Starts is doing, visit www.pinkpowermom.com.

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* 1. Are you

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* 2. Please tell us your zip code.

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* 3. How old are you?

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* 4. How many children do you have?

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* 5. How old are your children (mark all that apply)?

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* 6. Has a lack of childcare resources ever been an obstacle to your ability to access healthcare, support services or complementary/alternative care resources?

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* 7. Arranging childcare so that I or my family members can attend medical appointments, support services or complementary/alternative care is a challenge for me:

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* 8. Have you or your family members ever had to miss or reschedule a medical appointment, complementary/alternative care, or counseling appointment/support group due to lack of childcare resources?

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* 9. Have you ever used drop-in childcare services?

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* 10. If yes, have you used drop-in childcare services in the past . . .

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* 11. If yes, where? (check all that apply)

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* 12. If yes, how frequently?

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* 13. Would you use a drop in childcare center at the doctor,
complementary/alternative care provider or dentist?

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* 14. If yes, when (check all that may apply)?

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* 15. Would other services at the child care center be important to you, such as:

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* 16. How much are you willing to pay for this service for one child per hour (you may check more than one)?

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* 17. Given the choice between two medical service complexes,
would you be more likely to seek service from a medical complex that offered on-site drop-in childcare?

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* 18. Which hospital/medical center does your family most often frequent?

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* 19. Please tell us whether there is a hospital or medical center where you would like to see a My Little Waiting Room (list the name of the hospital or center and the city and state in which it is located).

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* 20. What determines where you receive your medical care?

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* 21. Please use this space for your feedback, comments and suggestions.

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* 22. Would you be willing to answer further questions about your experience as we develop our concept? If so, please provide your name and preferred contact information [NOTE: we will not sell your information, it will be used for our research purposes only.]

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* 23. Would you like to receive email updates about My Little Waiting Room?
If so, please enter your email address here:

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* 24. I learned about My Little Waiting Room through . . .

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