Family Child Care Interview Prescreen Form
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1.
What is your first and last name?
(Required.)
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2.
What is your email address?
(Required.)
3.
What is your licensing status?
Licensed
License-exempt
Other (please explain)
4.
What is the primary language you speak?
English
Spanish
Other (please specify)
5.
What is your gender identity?
Female
Male
Gender non-binary
Other (please specify)
Prefer not to respond
6.
With which race(s) do you identify? Choose all that apply.
American Indian or Alaska Native
Asian or Asian American
Black or African American
Native Hawaiian or other Pacific Islander
White
Prefer to self-describe (please describe)
7.
What is your ethnicity?
Hispanic or Latino/a/e
Not Hispanic or Latino/a/e
8.
How would you describe the location where you live?
Rural
Suburban
Urban
Other (please specify)
9.
What is your family child care group size?
1-4 children
5-10 children
More than 10 children
10.
What type of funding source do you receive? Choose all that apply.
Private (family) pay
Child care subsidy/assistance
CACFP (Child and Adult Care Food Program)
Head Start/Early Head Start
Public Pre-Kindergarten
Other (please explain)
11.
Please select the statements that apply to you. Choose all that apply.
I participate in my state's quality rating and improvement system (QRIS).
My child care program is accredited.
I am a member of a union.
I have participated in business training for my child care program.
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12.
Can you be available for a 60-minute interview between December 1, 2023 and January 31, 2024?
(Required.)
Yes
No
