NNCC

Child Care Needs Assessment 4

National Network for Child Care's Connections Newsletter

School-age Child Care Questionnaire

Please fill in all the blanks that you can and return this form in your child's Monday folder , in his/her backpack to the teacher, or to the PTA box in the office. Thanks so much!!!

1. What is your zip code?_________________

2. How MANY school-age children do you have in each of the following age
groups?
______ a. 0-4 years old
______ b. 5-8 years old
______ c. 9-12 years old
______ d. 13-15 years old

3. Please check one in each column for the type of care you USE and the type of care your PREFER.

	Type of care I use most of the time	Type of care I would prefer
a. care by parent in own home
b. care in relative's home
c. care in own home with relative
d. care in your home with non-relative
e. care in non-relative's home
f. child cares for self
g. child care center
h. combination of care as needed
i. currently searching for care
j. School-based program (like Bugg)
k. Other

4. Please check the days you need child care. Check all that apply.
___a. Monday - Friday
___b. Snowdays, holidays, summer breaks
___c. Other________________________

5. Please check the times you need school-age child care. Check all that apply.
___ a. Before school only
___ b. After school only
___ c. Before and after school
___ d. Other________________

6. 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.
___ a. No pay required
___ b. $1-24
___ c. $25-40
___ d. $41-60
___ e. $61-80
___ f. $81-100
___ g. $101-125
___ h. Over $125

7. Have you had any of these child care-related problems during the past year? Check problem areas.

Problem	Yes, I have had this problem
a. Cost of care
b. Finding temporary care
c. Finding care for sick child
d. Finding care for child with special needs
e. Location of care
f. Transporation to/from care
g. Dependability of care
h. Quality of care
i. Scheduling child care to match work schedule

Thank you very much for your assistance!!

Evaluation Tools Page

DOCUMENT USE/COPYRIGHT
National Network for Child Care - NNCC. Part of CYFERNET, the National Extension Service
Children Youth and Family Educational Research Network. Permission is granted to reproduce
these materials in whole or in part for educational purposes only (not for profit beyond the cost of
reproduction) provided that the author and Network receive acknowledgment and this notice is
included:

FORMAT AVAILABLE:: Internet
DOCUMENT REVIEW:: Level 3 - National Peer Review
ENTRY DATE:: April 1998