705 272 2051
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: *
Please check mark the type of child care needed: *
Please select type of care you are currently utilizing: *
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? *
Other: (please explain). *
To help assess funding needs, please indicate your household gross salary range. *
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. *
Please check the days you need child care. Check all that apply. *
Please check the times you need school-age childcare. Check all that apply. *
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. *
Have you had any of these child care related problems during the past year?Check problem areas. *
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