JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Are you a designated emergency child care center? We want to hear from you!
Thank you for working on the front lines to keep children and their families safe during this pandemic. We want to support you throughout this difficult time and continue to advocate on your behalf. Please complete this short survey so that we may understand your current experience and better support you.
We will not use your name or any identifying information about you when reporting the results of this survey unless we receive your consent.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Phone Number (where you may be reached for follow up)
*
Your answer
Email Address
*
Your answer
Confirm Email Address
*
Your answer
City/Town of program
*
Your answer
Zip Code of program
*
Your answer
Name of Program
*
Your answer
I am a (check all that apply):
*
Center child care director
Center child care owner
Other:
Required
How many children was your program serving on March 1st?
Your answer
2.
How many children are you providing emergency care for now?
Your answer
What age groups are currently enrolled at your program?
Infants
Toddlers
Preschool
School-aged
3.
How many staff members did you employ on March 1st?
Your answer
4.
How many staff members are currently working at your program?
Your answer
Was your remaining staff:
Fired
Laid off
Furloughed
Other:
Clear selection
Do you know whether the majority of your non-working employees have applied for unemployment?
Yes
No
Other:
Clear selection
6.
Do you have an adequate supply of cleaning products in order to meet the DCF requirements for operating as an emergency child care center?
Yes
No
Clear selection
7.
Do you have access to safety supplies, (gloves and other protective gear) in order to keep your staff and children safe?
Yes
No
Clear selection
Do you have access to other supplies such as food, milk, diapers, wipes, etc.?
Yes
No
Clear selection
8.
As an emergency child care provider, with added responsibilities for cleaning and safety, are you able to meet your monthly fiscal obligations (payroll, utilities, rent, etc.)?
Yes
No
Clear selection
Please explain any of your responses as well as any additional challenges you are currently facing.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of ACNJ.
Report Abuse
Forms