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* 1. Contact Information

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* 2. How many employees work for your company?

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* 3. What is the gender composition of your workforce?

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* 4. Have you experienced challenges hiring and retaining staff over the past 12 months due to lack of child care for employees' children?

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* 5. In the past year, what percentage of your employees have missed work because of childcare issues?

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* 6. Of the employees who have missed work because of child care issues, how often have they been late or missed work entirely?

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* 7. Do you currently offer benefits for employees' child care needs? Choose all that apply.

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* 8. What percentage of your employees might benefit from child care supports? (Consider number of employees who use Family or Employee + Child company sponsored health benefits.)

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* 9. Which of the following employer sponsored child care benefits would your company consider implementing if you received financial assistance? (Choose all that apply.)

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* 10. Are there any other issues related to your employees' ability to access child care that you would like for us to consider?

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