APITISAWIN
705 272 2051
lawrencemartin@apitisawin.com
Community Child Care Needs Assessment Survey
To develop a Day Care for Disabled and Non-Disabled Children
If you have parenting responsibilities, we would appreciate your time in helping us assess your
needs. Please complete the survey and return no later than December 31, 2016
Thank you for assisting us with this effort.
Email address
Would you use child care services if they were available to you? If yes, please complete the reminder of the survey.
Are you currently using child care services?
Please select the type of services you could use:
Required
Please check mark the type of child care needed:
Required
Please select type of care you are currently utilizing:
Required
Are you satisfied with your current child care arrangements?
If no, please explain
If you do not utilize child care services, what prevents you from using services?
Required
Other: (please explain).
To help assess funding needs, please indicate your household gross salary range.
Required
Number of people in house?
Is your household headed by a two-parent household or a single parent household?
How many children do you have in each of the following age groups?
0-4 years old
5-8 years old
9-12 years old
13-15 years old
Please check one in each column for the type of care you USE and the type of care you PREFER.
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
Current Day Care
School-based program
Please check the days you need child care. Check all that apply.
Required
Please check the days you need child care. Check all that apply.
Required
Please check the times you need school-age childcare. Check all that apply.
Required
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
Have you had any of these child care related problems during the past year?Check problem areas.
Required
Submit
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