MCH Childcare Needs Survey During COVID-19 Closure

Survey Questions

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* 1. What is your first and last name?

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* 2. At what email address would you like to be contacted?

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* 3. Please select how many children you will need childcare for in each program level.

	1	2	3	4+	None
Infant	Infant 1	Infant 2	Infant 3	Infant 4+	Infant None
Toddler	Toddler 1	Toddler 2	Toddler 3	Toddler 4+	Toddler None
Early Childhood	Early Childhood 1	Early Childhood 2	Early Childhood 3	Early Childhood 4+	Early Childhood None
Elementary/Middle School	Elementary/Middle School 1	Elementary/Middle School 2	Elementary/Middle School 3	Elementary/Middle School 4+	Elementary/Middle School None

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* 4. Please select your childcare day and time needs.

	Monday	Tuesday	Wednesday	Thursday	Friday
8:00-12:00 PM	8:00-12:00 PM Monday	8:00-12:00 PM Tuesday	8:00-12:00 PM Wednesday	8:00-12:00 PM Thursday	8:00-12:00 PM Friday
12:00-4:00 PM	12:00-4:00 PM Monday	12:00-4:00 PM Tuesday	12:00-4:00 PM Wednesday	12:00-4:00 PM Thursday	12:00-4:00 PM Friday
8:00-4:00 PM (All Day)	8:00-4:00 PM (All Day) Monday	8:00-4:00 PM (All Day) Tuesday	8:00-4:00 PM (All Day) Wednesday	8:00-4:00 PM (All Day) Thursday	8:00-4:00 PM (All Day) Friday

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* 5. Do you work or volunteer in any of the following fields: medical/healthcare, emergency services or first responders?

Yes

No

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* 6. Would your financial livelihood be adversely impacted due to lack of childcare?

Yes

No

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* 7. Would your employment be adversely affected if you could not report to work due to lack of childcare?

Yes

No