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13<br />

Appendix 4:<br />

Sample Employee Childcare<br />

Needs Questionnaire 4<br />

General Directions<br />

PART I: DEMOGRAPHIC INFORMATION<br />

1. What is your gender?<br />

❑ Female<br />

Male<br />

❑<br />

2. What is your age:<br />

25 years or under<br />

26 - 30 years<br />

31 - 35 years<br />

35 - 40 years<br />

41 - 45 years<br />

45 years or over<br />

❑<br />

❑<br />

❑<br />

❑<br />

❑<br />

❑<br />

3. What is your home postcode?<br />

a.Child #1 (youngest)<br />

❑ Under 1 Year ❑ 1 - 2 Years<br />

❑ 2 - 3 Years ❑ 3 - 5 Years ❑ 6 - 12 Years<br />

Where your child receives care (Check all that apply.)<br />

❑ Nursery or crèche<br />

❑ Nanny in my home<br />

❑ Childminder in their home<br />

❑ Partner in my home<br />

❑ Another family member<br />

❑ Before/After School Programme<br />

❑ Nursery (attached to prep school)<br />

❑ Nursery (attached to primary school)<br />

Other (Please specify)<br />

❑<br />

________________________________________________<br />

Average Weekly Cost ______________________ per week<br />

How satisfied are you with the care? (Check one)<br />

Very dissatisfied ❑ Dissatisfied<br />

❑<br />

❑ Mixed feelings ❑ Satisfied ❑ Very satisfied<br />

_________________________________________________<br />

page 38

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