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Family Survey

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I.            Your Family - (parents and children living together).

            A.            Your family's ages:           

            (please list all members (i.e., mother, father, etc. & their ages)

            B.            Your family's current employment:

                        1.            Where does each adult family member work (even if it's part time)?                                   

                        2.            How long have they worked there?                                            

                        3.            Are they       Full time?       Part time?

            C.            What health problems concern you and your family?

      (write the name of the family member and the kind of health problems)

            Family Member:    
      
            o            Cancer
            o            Diabetes
            o   Hearing/Vision
            o   Bronchial problems
            o            Allergies
            o            Other                 

            Family Member:           

            o            Cancer
            o            Diabetes
            o   Hearing/Visual
            o   Bronchial problems
            o            Allergies
            o            Other                 

 

            D.            Level of Education (all)
                    1.      Name schools attended by each family person and the number of years at each school.

                              School                                                    Years Attended

                             _______________________________________________________

                            _______________________________________________________

                            _______________________________________________________

                           _______________________________________________________

 

E.            Has you family experienced any of the following life events during the four year period? (Circle all that apply)

                  Separation/divorce                                    2007                  2008                  2009                  2010                 2011

                  Loss of job                                                  2007                  2008                  2009                  2010                 2011

                  Homelessness                                           2007                  2008                  2009                  2010                 2011

                  Birth of a child                                            2007                  2008                  2009                  2010                 2011

                  Death of a family member                        2007                  2008                  2009                  2010                 2011

                  Serious illness                                           2007                  2008                  2009                  2010                 2011

                  Single parenthood                                    2007                  2008                  2009                  2010                 2011

                  Other                                                            2007                  2008                  2009                  2010                 2011

 

II.            Involvement of Family in the Program

        1.___ From what source did you hear about the Christian Family outreach program?

                                2.___ On a fairly regular basis have you or your spouse/relative participated in any of the following activities? 

            (check all that apply)


o      teacher/parent meetings

o      visits to the program

o      playing with your children

o      parent support activities

o      volunteering in the program

o      taking children on an

o      parent to parent counseling

o      reading at home to children

o      Informal teacher/parent phone calls or conversations

 

III.            How well do you understand the Academic Challenge Program?  Please indicate how you feel by checking one box for each item listed below.

                       

1.   Do you feel you understand:

I do

I'm not sure

I don't

a.   the goals and objectives of the program?

 

 

 

b.   how each child's daily activities are selected?

 

 

 

c.   what specific curriculum is used?

 

 

 

d.   how the staff evaluates each child's progress?

 

 

 

e.   how the staff works as a team?

 

 

 

f.    how staff members operate the program within the mission of the total agency?

 

 

 

g.   the role of staff in relationship to parents?

 

 

 

h.   the role of staff in relationship to children?

 

 

                    

 

2.   How satisfied are you with various aspects of the program?  (please indicate how you feel by checking one box for each item listed)

I'm Satisfied

I'm Not Satisfied

I'm Not Sure

I'm Not Very Satisfied

I'm Not at all Satisfied

discipline & organization

 

 

 

 

 

methods of teaching

 

 

 

 

 

location & lay-out of rooms

 

 

 

 

 

materials, toys & equipment used

 

 

 

 

 

amount of contact with staff

 

 

 

 

 

effectiveness of staff with parents

 

 

 

 

 

effectiveness of staff with children

 

 

 

 

 

Ask Dr. Susan