Child Care Questionnaire

Assess the availability and quality of child care services in your community with this questionnaire template.




How many children do you have living with you for whom you are the care-taker? Please check the appropriate age box in the table below for each child.

Expecting < 1 year 1 Year 2 Years 3 Years 4 Years 5 to 12 years N/A
Child 1
Child 2
Child 3
Child 4
Child 5

Are you the sole care-taker for your child(ren): e.g., a single parent, sole provider?

Yes
No

Do you have a child/children with special needs?

Yes
No

If you answered 'yes', please specify what special needs your child/ren has/have.

What is your total annual gross HOUSEHOLD income?

Less than $20,000
$20,000 to $29,000
$30,000 to $39,000
$40,000 to $49,000
$50,000 to $59,000
$60,000 to $69,000
$70,000 to $79,000
$80,000 to $89,000
$90,000 to $99,000
$100,000 or more

What is your gender?

Male
Female
Other:

How many hours per week do you typically work for pay?

0-10 hours
11-20 hours
21-39 hours
40 hours or more

Typically, what days/shifts do you work for pay? (Check all that apply)

Weekdays
Weeknights/evenings
Flexible schedule (varies per week)
Seasonal schedule (varies per season)
Other (please specify):

What types of child care providers do you currently use for any of your children? (Check all that apply.)

Spouse/significant other
Other relatives
Unrelated care-taker in your home
Unrelated care-taker in their home
Center-based care
Before/after school care
Summer camps
None (child(ren) care(s) for self/selves )
Other (please specify):

How many hours per week are EACH of your children typically in the care of a child care provider?

0-10 hours 11-20 hours 21-30 hours 31-40 hours 40 + hours Not Applicable
Child 1
Child 2
Child 3
Child 4
Child 5

If you have a child/children with special needs, are those needs met at your child care provider?

Yes
No

Do you use more than one child care provider to meet your child care needs?

Yes
No

What is the total weekly child are expenses for your child(ren)?

None (have free child care)
Less than $50 per week
$51 to $150 per week
$151 to $250 per week
$251 to $350 per week
$351 to $450 per week
$451 to $550 per week
$551 or more per week

How far do you travel, one way, to transport your child(ren) to child care ?

0-5 miles
6-10 miles
11-30 miles
31-45 miles
46 or more miles

What is your commute like to work?

Drive alone
Carpool/Rideshare service
Public transit (train or bus)
Bike
Unemployed/Remote
Other

Do you receive subsidized child care assistance?

Yes
No

Evaluate each service listed below:

I do not need I wish I had but don't I currently/will soon use
Infant care
Full-day child care (30 hours or more per week)
Part-day/part-time child care (less than 30 hours a week)
Before/after school care Summer program(s)
Evening (after 5 pm) or night care for work hours (second or third shift)
Emergency or occasional drop-in care
Special needs child care
Child care for multiple age groups (so all children can use one provide)

For EACH item below, please check the number of times the following child care-related instances have occurred in the last six months.

None 1 to 3 times 4 to 7 times 8 or more times
I was late getting to work due to transportation needs of child care.
I didn't go to work due to school vacation/teacher in-service days.
I was late to work due to a change in child care plans.
I had to leave work early to pick up child from child care center/provider.
I brought my child to work.
I needed child care for my third shift work hours.

Please rate the importance of EACH feature below that you consider (or would consider in the near future) when selecting a child care program.

Of no importance Of a little importance Of some importance Of much importance Of critical importance
Cost of Program
Location: close to home or enroute to work.
Convenient hours (long regular hours, e.g. 6 am to 7pm)
Availability of evenings and/or night care (for work hours/second or third shift)
Availability of sick child care
Availability of emergency or occasional drop-in care
Availability of flexible hours/days (for part-time work)
Availability of summer programs
Ratio of staff to child
Quality of staff
Short or no waiting list
Special needs accommodation
Multiple age group care (so all children can use one provider)
Safety and security features
Curriculum / program approach
Dietary preferences/needs