Page 77 - Creating a Community of Resiliency

Appendix C: Provider Focus Group Survey
1. I am (please choose one answer):
2. I have been a child care provider for (please choose one answer):
3. The zip code of my child care business is:
4. Number of children I serve: _________
5. Age of the child(ren) I serve (check all that apply):
6. My age (in years): _______ years
7. My highest level of education is (please choose one answer):
8. My preferred language is (please choose one answer):
9. I identify my race/ethnicity as (check all that apply):
10. My total family income per year is (please choose one answer)
11. Have you received information regarding the following, from Resources and Referral (R&R) agencies?
 A family child care provider
 Center-based staff
Other: ________________
Less than a year
1-5 years
6 years or more
 Under 3 years old
3-5 years old
6 years or older
No high school diploma/No GED
High school diploma/GED
 Some college
 Associate’s degree
 Bachelor’s degree
Master’s degree
 Doctoral degree
 English
 Spanish
 Chinese
 Other (Please specify) :____________
American Indian / Alaska Native
 Asian
 Biracial/Multiracial
Black /African American
Hispanic/Latino
Native Hawaiian/ Pacific Islander
 White/Caucasian
Other: ____________
Less than $12,000
 $12,000-$19,999
 $20,000-$34,999
 $35,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000 or more
Please circle “Yes” or “No” for each item.
Laws and requirements for emergency preparedness in child care How to be prepared for an emergency while children are in your care How to respond during an emergency while children are in your care
Yes No
Yes No Yes No Yes No
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