Kinship Family Institute Caregiver Survey

Hello! We are in the process of establishing the Kinship Family Institute (KFI), which will provide needed services for kinship families — those in which children live with relatives or close family friends. We are interested in learning what services or supports you currently use as well as what additional services or supports are needed. This survey should only take approximately 10 minutes to complete. By completing the survey you are agreeing to allow us to use your information to help us build KFI programs. If you would rather complete the survey by phone, please call 703-246-4KIN or 703-246-4546. Thank you in advance for your participation.

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* 1. ID#

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* 2. Are you currently a kinship caregiver?

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* 3. If yes, then how many kinship children are you providing care to?

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* 4. Are you also raising your own children?

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* 5. Please indicate the ages and genders of all the children you are raising.

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* 6. Are you in contact with any of the biological parents of the kinship children you are raising?

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* 7. What factors have contributed to your providing kinship care? (Choose all that apply)

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* 8. How are you related to the kinship children in your care (i.e. paternal grandmother)?

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* 9. How long have you been providing kinship care?

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* 10. Do you have legal custody of the kinship children in your care?

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* 11. Are you currently receiving any support or services for the care you are providing to your kinship children?

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* 12. If yes, then what type of services or support?

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* 13. Do you need help finding services for your family?

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* 14. Are you interested in participating in some type of support group?

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* 15. Are you interested in respite services, a chance for you to take a break, if only for a couple of hours?

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* 16. If yes, then when? (Choose all that apply)

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* 17. Are you interested in workshops, seminars or trainings?

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* 18. If yes, then what type of workshops, seminars or trainings? (Here are some possibilities: challenging behaviors of children, parenting skills for kinship caregivers, legal issues, raising teenagers)

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* 19. Do you need help accessing legal services?

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* 20. If yes, then what type of legal services? (Choose all that apply)

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* 21. Are there any other services or supports you need that have not yet been identified? If so, please describe.

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* 22. What is your date of birth?

Date

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* 23. What is your gender?

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* 24. What is your race/ethnicity?

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* 25. What is your primary language?

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* 26. What is your zip code?

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* 27. Which best describes your current employment status?

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* 28. Are there other adults in your household helping to raise the children?

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* 29. How many adults (not including yourself) in your household are employed?

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* 30. Would you be willing to allow us to contact you for additional information to help develop our services for kinship families in Fairfax County? If you are interested, please provide your name and contact information. Thank you for your time!

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* 31. Additional Comments

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