For the Purpose of this survey, a Crisis Nursery is: a type of respite care that provides temporary relief for families and caregivers in situational emergencies and helps prevent out-of-home placement and possible abuse and neglect toward children ages 0 through 5.

1. Would you use a respite service if it were available?

Yes

No

If yes, in what kind of situation are you likely to use the service?

  Planned

  Crisis or emergency

  Both

  Other (please specify):

2. Do you know someone who would use a respite service if it were available?

Yes

No

If yes, in what kind of situation would he or she be likely to use the service?

  Planned

  Crisis or emergency

  Both

  Other (please specify):

3. If the following kinds of services were available, which would you use?  (Check all that apply)

  A sitter who comes to my home and provides care for less than 12 hours

  In-home sitter for overnight

  In-home sitter for more than 24 hours consecutively

  Services in a center away from my home for less than 12 hours

  Services in a center overnight

  Services in a center for more than 24 hours consecutively

  A provider who cares for my family member in their own home for less than 12 hours

  Services at a care provider’s home overnight

  Services at a care provider’s home for more than 24 hours consecutively

4.  How frequently do you feel you would need/want respite services?

  Weekly

  Several times a month

  Monthly

  Every couple of months

  Less than 6 times a year

5. When would you most likely use/need respite care?

  Evenings

  Holidays

  School holidays

  Weekends

  Weekdays

  “Time Out”

  Summer

  Other (please specify):

6. How many children, between zero through age five, would you take to the nursery?

Number of children under age 1:

Age 1:

Age 2:

Age 3:

Age 4:

Age 5:

7. If you have other children in the home over age five, would you also need care for them at the same time?

  Yes, always

  Yes, sometimes

  No

8. Check any of the following reasons which might prevent you from using the services

  Money

  Family schedules

  Transportation

  Lack of confidence in care providers

  Family members who don’t approve

  Fear of legal repercussions

  None

  Other (please specify):

To submit this survey, please click the submit button.  Thank you for your time!