ECE405 Children & Families in a Diverse Society
The purpose of this survey is to obtain your insight about how to better understand the needs of our children and families. Your feedback is very important and will be kept confidential. Thank you for taking the time to answer these questions. This information is very helpful, as we continue to develop a partnership to care for and educate our children together. If you would prefer to complete this form directly with one of our staff members, we can arrange a time to talk with you about this information. Please fill out only one survey per family. 1. What descriptor best describes you?
a. Parent b. Foster Parent c. Grandparent/Guardian d. Teen parent e. Other________________
2. Your gender/sex:
a. Male b. Female
3. Your age:
a. 15 and under b. 16-‐21 c. 22-‐27 d. 28-‐33 e. 34-‐39 f. 40-‐45 g. 46-‐51 h. 52-‐58 i. Over 60
4. Your ethnicity/race:
a. White b. African-‐American c. Asian/Pacific Islander d. Native American e. Alaskan f. Hispanic g. Other__________
5. What is the primary language spoken in your home?
a. English b. Spanish c. Other_________
6. What is your marital status?
a. Single b. Married c. Divorced d. Separated e. Living with my partner f. Widowed g. Other__________
7. Who lives in your home? Mother, child, and one sibling 8. Number of children in the home?
Ages Child(ren) 0 to 2 years old 1 3 to 5 years old 1 (Child) 6 to 13 years old 14 to 17 years old
9. What is your education and employment status (check all that apply)?
Mother Education Status Father Some High School High School Graduate X Vocational School
X Some College Associate Degree Bachelor Degree Graduate Degree/Advanced Graduate Degree
Mother Employment Status Father
X Employed full-‐time Employed full-‐time Seeking employment Unemployed X Pursuing Education/Professional Training Other _______________
10. Does your family live:
a. Alone as a family b. With relatives c. With friends d. In a shelter e. Homeless f. Other_______
11. Do you have health insurance?
a. Yes b. No
12. Does your child(ren) have health insurance?
a. Yes b. No
13. If you don’t have insurance, are you eligible for Medicaid?
a. No b. Yes c. Don’t know
14. Does your family have reliable transportation?
a. No b. Yes, car c. Yes, carpool or ride sharing d. Yes, public transportation e. Other________________
15. What type(s) of childcare are you currently using?
a. No other childcare used b. Older siblings c. Relatives d. Babysitter in the home e. Babysitter outside the home f. Other___________
About how many hours per week is your child (ren) in child care? ____40+ hours_____________ 16. What is your annual household income?
a. Less than $10,000 b. $10,000 -‐ $14,999 c. $15,000 -‐ $24,999 d. $25,000 -‐ $34,999 e. $35,000 -‐ $44,999 f. $45,000 -‐ $54,999 g. Over $60,000
17. Do you receive Public Assistance?
a. No b. Medicaid c. Social Security d. Food Stamps e. Housing f. Workers Compensation g. Unemployment Benefits h. Other_________________
18. Where would you like to receive support (Circle all that apply):
a. Education b. Employment services c. Food and nutrition support d. Health-‐related or medical help e. Budgeting or stretching income f. Housing improvements g. Resources in community h. Emergency rent, utility or shelter help i. Transportation j. Divorce Support Group k. English as a Second Language
19. Which community resources do you use or wish to use (Check all that apply):
Use Currently Would like to use Community organizations X Crisis intervention & counseling Education, literacy & mentoring Employment & training Mental health services Information & referral Substance abuse treatment Emergency assistance (food, etc) Child welfare & foster care Law enforcement Culture & art Transportation Family support services X Public health services (IHS) Legal aid Recreation Youth Boys and Girls Club Churches & Spiritual organizations
20. How would you like to be involved in your child’s school experience?
a. Helping in the classroom b. Helping with field trips and special events c. Serving on Parent Committee d. Translating, verbal or written e. Special Projects f. At Home Projects g. Other______________________