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* 1. What is your age?

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* 2. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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* 3. If applicable, what school district are you in?

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* 4. Which of the following categories best describes your employment status?

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* 6. What kind of business or industry best describes your employer? (For example, construction, hospital, manufacturing, distribution, education, etc.)

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* 7. What is your position within the company?

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* 9. What shifts?

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* 10. Please check the age range of your child(ren). Check all that apply.

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* 11. Which best describes your childcare provider?

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* 12. If you have childcare, what is the distance you travel from your place of employment to your childcare provider?

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* 14. Do you find it difficult to find childcare for any of the following? Check all that apply.

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* 15. How often have you experienced any of the following as a result of having a childcare issue? Please check all that apply.

  Never Sometimes Often
Missed a day of work
Been late to work
Reduced regular work hours
Took personal time off
Been distracted at work
Been unproductive at work
Changed from full-time to part-time work
Had to leave the position

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* 19. What are you paying now for childcare weekly per child?

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* 20. What do you consider a fair price to pay for childcare weekly per child?

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* 21. What is the maximum you are able to afford for childcare weekly per child?

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* 22. Please indicate how important it is for Virginia to make investments and pass childcare policies to address the issues below. Please rate 1-3, with 1 being most important and 3 being least important.

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* 23.  Please describe your most significant issue or concern regarding your childcare needs.

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