ECE 405 dis 2
shahea
survey.docxThe 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?
1 child age 3 to 5
9. What is your education and work status?
Some college
Employed full time
10. do you live with
a. relatives
b. alone as a family
11. Do you have health insurance?
Yes
12. Does your family have reliable transportation?
Yes a car
13. What type of childcare do you currently have?
Relatives
14. What is your yearly household income?
$35,000 --‐ $44,999
15. Do you receive public assistance?
No
16. How would you like to involve in your child’s school experience?
