Family and Caregiver Needs Assessment
Do you find it hard to handle the new roles you are assuming due to the COVID19 health emergency?
Are you working from home while homeschooling or caring for your kids? Do you feel like your family needs resources to deal with the stress and fear associated with the pandemic?
We would like to share resources and provide support. This survey will help us identify the priorities.
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Which of the following describes you? Check all that apply.
Parent or guardian
What new role/s have you had to assume while in quarantine? Check all that apply.
Child care provider
Doctor or Nurse
Personal trainer/fitness specialist
What age group are the children/students you are caring for and/or teaching. Check all that apply
Infants up to 18 months
Toddler (18 months to 36 months)
Preschooler (3 to 5 years)
First through third grader
Fourth through ninth grade
High school student
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This form was created inside of University of Dayton.