Family Child Care Interview Prescreen Form

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* 1. What is your first and last name?

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* 2. What is your email address?

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* 3. What is your licensing status?

Licensed

License-exempt

Other (please explain)

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* 4. What is the primary language you speak?

English

Spanish

Other (please specify)

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* 5. What is your gender identity?

Female

Male

Gender non-binary

Other (please specify)

Prefer not to respond

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* 6. With which race(s) do you identify? Choose all that apply.

American Indian or Alaska Native

Asian or Asian American

Black or African American

Native Hawaiian or other Pacific Islander

White

Prefer to self-describe (please describe)

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* 7. What is your ethnicity?

Hispanic or Latino/a/e

Not Hispanic or Latino/a/e

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* 8. How would you describe the location where you live?

Rural

Suburban

Urban

Other (please specify)

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* 9. What is your family child care group size?

1-4 children

5-10 children

More than 10 children

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* 10. What type of funding source do you receive? Choose all that apply.

Private (family) pay

Child care subsidy/assistance

CACFP (Child and Adult Care Food Program)

Head Start/Early Head Start

Public Pre-Kindergarten

Other (please explain)

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* 11. Please select the statements that apply to you. Choose all that apply.

I participate in my state's quality rating and improvement system (QRIS).

My child care program is accredited.

I am a member of a union.

I have participated in business training for my child care program.

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* 12. Can you be available for a 60-minute interview between December 1, 2023 and January 31, 2024?

Yes