Please take a few minutes to complete this survey. Your response is very important in helping us to increase the quality of our referral services and to better meet the needs of parents who are searching for child care. Name: Your City: Referral Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20112012201320142015 Name of Referral Specialist: (Optional) I would use the Referral Services again and/or tell someone else about this service. Yes No The assistance that I received from the Referral Specialist was helpful in my search for child care. Highly Agree Agree Somewhat Agree Disagree The materials I received were informative and helpful. Highly Agree Agree Somewhat Agree Disagree The overall referral process met my expectations. Highly Agree Agree Somewhat Agree Disagree The Referrals I received met my expectations and the needs of my family. Highly Agree Agree Somewhat Agree Disagree I am satisfied with the accuracy of the information. Highly Agree Agree Somewhat Agree Disagree I used the following resources when choosing child care (Check all that apply) Child Care Checklist for Parents How Do You Choose Child Care (Booklet) Building for the Future (Food Program Brochure) Health Care Coverage for Children (Flyer) IRIS (Immunization Brochure) Need Help? Dial 2-1-1 (Flyer) Idaho Child Care Program (Brochure) Other If Other, Please Specify: Was there anything that you needed and did not receive from the referral specialist? Yes No If Yes, please explain: Did you select child care? Yes No If yes, are you satisfied with the care provider you have selected? Yes No I experienced the following: (check all that apply) No problems Care not available for hours needed No opening in age group needed Preferred center care not available Cost too high Care not available for my location Quality unsatisfactory Preferred family care not available Other If Other, Please Specify: Additional Comments:
