Family Survey
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.
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1. Do you feel you understand: |
I do |
I'm not sure |
I don't |
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a. the goals and objectives of the program? |
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b. how each child's daily activities are selected? |
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c. what specific curriculum is used? |
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d. how the staff evaluates each child's progress? |
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e. how the staff works as a team? |
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f. how staff members operate the program within the mission of the total agency? |
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g. the role of staff in relationship to parents? |
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h. the role of staff in relationship to children? |
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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 |
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discipline & organization |
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methods of teaching |
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location & lay-out of rooms |
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materials, toys & equipment used |
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amount of contact with staff |
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effectiveness of staff with parents |
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effectiveness of staff with children |
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