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* 1. Zip code

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* 2. Age

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* 3. Gender

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* 4. Ethnicity

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* 5. Race

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* 6. Number of family members in household

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* 7. Income (estimate)

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* 8. Employment status

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* 9. Education status

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* 10. How many BOYS ages 0 to 5 do you take care of?

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* 11. How many GIRLS ages 0 to 5 do you take care of?

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* 12. Who helps you to take care of your child(ren) on a daily/weekly basis?

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* 13. Thinking back to the last 6 months, what services, relationships or other factors have helped you to ensure your child(ren) will be ready for school and/or successful in life?

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* 14. What childcare arrangements do you use MOST FREQUENTLY?

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* 15. On a scale of 1 to 5 (where 5 = severe daily stress; 1 = no stress), rate the level of stress you experience related in the following areas:

  No stress Severe stress
Diapers
Other baby supplies
Food or milk/formula
Childcare affordability
Childcare quality (it may be affordable, but is my child learning, engaged and being treated with the utmost care)
Transportation
Housing
Employment
Utility assistance
Safety (neighborhood or household level)
Healthcare/insurance
Relationships with family members
Relationship with other parent
Technology/communications (lack of consistent computer, phone, etc.)
Finding information about free or low-cost services and resources

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* 16. When you have a problem or need resources to meet your needs related to your young child(ren), how likely are you to go to each the following for assistance?

  Not likely at all Very likely
Friends/family
Neighbors
Church
Employer/co-workers
Internet search
Social media (Facebook, etc.)
211 resource line
Medical provider/child’s pediatrician
Community organization such as library, non-profit organization or recreation center

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* 17. If you had your preference, where/how would you PREFER to access information or assistance for your family needs? (select up to 5 - fewer is better)

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* 18. Are you AWARE of the following services? (check all that apply)

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* 19. Of these services, which have you USED (or attempted to use) in the past? (check all that apply)

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* 20. For services you knew about, but have NOT used (or discontinued using), please:
-- name the service(s)
-- share why you didn't use them, or why you stopped using them
-- tell us what you used instead

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* 21. If accessible to you and your family, would you utilize counseling services to help manage stress or relationships?

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* 22. If you answered yes to the above question, would you prefer that the provider (counselor, doctor etc.) be of the same ethnic background as you?

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* 23. Would you participate in a support group to share and learn more about: (check all that apply)

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* 24. What EXCELLENT programs, services or practices have you seen that are TRULY EFFECTIVE in meeting the needs of parents with young children?

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* 25. What types of NEGATIVE MESSAGING have you heard that impacts how you feel about childcare systems and services, or the people who represent these institutions?

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* 26. Do you feel like your parenting is judged by others?

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* 27. If you answered ‘yes’ above, who is doing the judging?

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* 28. At times when you have felt loved and/or properly supported to help meet your needs, what made you feel good about the experience?

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* 29. Do you know any other people or groups we can connect with to ask these same questions, where we might get more good information? (if so, please share any details)

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* 30. Do you have a need NOW that we can assist with?

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* 31. If you answered 'yes' to the above question, or would like us to follow up with you for some other reason, please type your:
- First and last name
- Preferred method of contact (e.g., phone number, email)
- Request(s) for assistance/follow-up at this time

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* 32. Please share any additional information that you feel is important for us to know. (optional)

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