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Community Child Care Needs Assessment Survey
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1.
Would you use child care services if they were available to you?
(Required.)
Yes
No
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2.
Are you currently using child care services?
(Required.)
Yes
No
3.
Identify the type of services you use by age range
Infant (Birth to 11 months) - Number of Children
Toddler (11 to 36 months) - Number of Children
Preschool (3 to 5 years) - Number of Children
After School Care (K-6th grade) - Number of Children
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4.
Please mark the type of child care needed
(Required.)
Full Time
Half Days (5 days a week)
Partial Week (2 or 3 times/wk)
Half Days-Partial Week (2 or 3 times/wk)
After School Care
Night Care or Evening Care
Sick Child Care
Other (please specify)
5.
Please mark the location/type of care you are currently utilizing
Day Care Center - Number of Children
Family Care Center - Number of Children
Provider in my own home - Number of Children
Care by family members - Number of Children
After school care - Number of Children
Care by older sibling - Number of Children
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6.
Are you satisfied with your current child care arrangements?
(Required.)
Yes
No
If no, please explain
7.
If you do not utilize child care services, what prevents you from using services?
Cost
Availability
Location
Vanpool/Carpool
Hours of Operation
Happy with current provider
Other (please specify)
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8.
To help assess funding needs, please indicate your household gross salary range
(Required.)
below $20,000
$20,000-$29,000
$30,000-$39,000
$40,000-$49,000
over $50,000
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9.
Is your household headed by a two-parent household or a single parent household?
(Required.)
Single parent
Two parent
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10.
How many children do you have in each of the following age groups
(Required.)
0-4 years old
5-8 years old
9-12 years old
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11.
Which care would you PREFER?
(Required.)
Care by parent in own home
Care in relative's home
Care in own home with relative
Care in your home with non-relative
care in non-relative's home
child care for self
child care center
combination of care as needed
currently searching for care
School-based program
Other
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12.
Please check the days you need child care. Check all that apply
(Required.)
Monday-Friday
Holidays, summer breaks
Other
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13.
Please check the times you need school-age child care. Check all that apply
(Required.)
Before school only
After school only
Before and after school
Other
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14.
Please check the amount you consider reasonable to pay for child care PER MONTH/WEEK/PER CHILD during the regular school year. Check only one
(Required.)
No pay required
$1-$24
$25-$40
$41-$60
$61-80
$81-$100
$101-125
Over $125
15.
Have you had any of these child care related problems during the past year?
Cost of care
Finding temporary care
Finding care for sick child
Finding care for child with special needs
Location of care
Transportation to/from care
Dependability of care
Quality of care
Scheduling child care to match work schedule
