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* 1. What is your postal code?

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* 2. What is your gender?

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* 3. In general, do you think families in our community (Hot Springs and surrounding areas) have access to adequate supply of childcare service?

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* 4. Do you currently have any children 12 and under living at home?

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* 5. What ages of children do you have? (check all that apply)

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* 6. Are you pregnant, planning to become pregnant or adopt in the next year?

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* 7. Are you currently using childcare services?

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* 8. If yes, please identify the type of services you currently use:

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* 9. Please indicate the location/type of childcare you are currently using:

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* 10. How much do you pay for a week of childcare (per child)?

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* 11. If searching for childcare, please indicated what you are most interested in (location/type)

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* 12. When do you typically work?

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* 13. When does your spouse/partner typically work?

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* 14. Please indicate the childcare needed

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* 15. Please indicate the childcare needed (continued)

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* 16. Have child care issues ever caused you to (check all that apply)

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* 17. If you do not utilize child care services, what prevents you from using services?

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* 18. Is your household headed by a two-parent or single parent household?

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* 19. To help assess funding needs, please indicate your household gross salary range.

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