Child Care Referral Feedback Form

Thank you for visiting The Childcare Network for child care information. Please take a moment to give us your feedback. This information helps us improve our services.

Name:
Zip Code:

  1. How satisfied are you with the quality of your available child care options?
    Very Satisfied Satisfied Somewhat Satisfied Not Satisfied Not sure Does not apply

  2. How satisfied are you with the quality of the care you chose?
    Very Satisfied Satisfied Somewhat Satisfied Not Satisfied Not sure Does not apply

  3. What type of care did you chose?
    Center Providers Home In My Home Preschool
    Friend/Relative Care Head Start Before/After School
    Camp Parent's Day Out Still looking Decided not to use child care
    Found a program not on the list.

  4. Did you have a problem finding care?
    No Yes
      If yes, please indicate reason:
      Cost No openings Available hours Location
      Quality Transportation Other:
      Does not apply

  5. Which of the following quality indicators do you use in choosing child care? (check all that apply)
    Caregivers/Teachers Activities/Curriculum Setting/Environment
    Adult/Child Interactions Other:


Please rate your experience with our agency staff:
  1. Courtesy and helpfulness:
    Excellent Very Good Good Fair Poor Not Sure Does not apply

  2. Knowledge/counseling:
    Excellent Very Good Good Fair Poor Not Sure Does not apply

  3. Response time:
    Same day 1-2 days 3-5 days 6-7 days More than a week Not Sure N/A

  4. Accuracy of information:
    Excellent Very Good Good Fair Poor Not Sure Does not apply

  5. Quality of information:
    Excellent Very Good Good Fair Poor Not Sure Does not apply

  6. Were you able to make a better decision regarding child care based on our services and information?
    Yes No Not Sure

  7. Did your understanding of available resources such as financial assistance, child health insurance or other community resources for families increase?
    Yes No Not Sure

  8. Would you use our service again?
    Yes No Not Sure

  9. Would you recommend this service to others?
    Yes No Not Sure

  10. How did you access this service?
    Phone Internet Email Fax In person

  11. Would you be interested in being contacted for advocacy efforts? If so, please include your phone or email contact information:


  12. How could we improve our service to families?

Thank you!