The Home-Based Child Care Toolkit for Nurturing School-Age Children Pilot Study

Instrument 4

HBCC-NSAC Toolkit Family Questionnaire

Home-Based Child Care Toolkit for Nurturing School-Age Children (HBCC-NSAC Toolkit): Family Questionnaire

What is an HBCC provider?

For this questionnaire, “home-based child care provider” is a person who takes care of your child(ren) in a home. For you, this might be a professional caregiver (like a family child care setting) or a family member, friend, or neighbor. We will refer to the person who shared this questionnaire with you as “your child’s provider” throughout this questionnaire.

Your child(ren)’s home-based child care (HBCC) provider (see box) plays an important role in caring for your child(ren) and helping them reach their full potential. Talking with your child’s provider about your child(ren)’s growth and learning can help you work together to support your child(ren).

This questionnaire is part of a larger toolkit that your child’s provider is using to help improve their own practices with school-age children. “Practices” include all the ways your child’s provider interacts with and does things with your child(ren). This questionnaire is meant to help you and your child’s provider find out what is important to talk about together. Based on your answers, we encourage you to bring up the things that are important to you and talk about them with your child’s provider!

First, please enter the time you start this questionnaire. Start Time: _______

The Paperwork Reduction Act Burden Statement: This collection of information is voluntary and will be used to learn about the experiences of home-based child care providers. Public reporting burden for this collection of information is estimated to average 10 minutes including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number for this collection is 0970-0355 and the expiration date is 08/31/2024. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Patricia Del Grosso, 600 Alexander Park, Suite 100, Princeton, NJ 08540; Attn: OMB-PRA 0970-0355.

Part I

Instructions: Write in your responses to these short answer questions for your children cared for by the HBCC provider who shared this questionnaire with you (we refer to this person as “your child’s provider”). For example, if you have 3 children cared for by your child’s provider, fill out the information for Child 1, 2, and 3. There is space for up to 4 children.

1a. What is your relationship to Child 1?

□ Primary parent or guardian

□ Grandparent

□ Other relative

□ Other non-relative

1b. Is Child 1 of Hispanic, Latino/a, or Spanish origin?

□ Yes

□ No

1c. What is Child 1’s race? Check all that apply.

□ American Indian or Alaska Native

□ Asian

□ Black or African American

□ Native Hawaiian or Other Pacific Islander

□ White

□ Another race (please fill in): ____________________

1d. Child 1’s age:____________

2a. What is your relationship to Child 2?

□ Primary parent or guardian

□ Grandparent

□ Other relative

□ Other non-relative

2b. Is Child 2 of Hispanic, Latino/a, or Spanish origin?

□ Yes

□ No

2c. What is Child 2’s race? Check all that apply.

□ American Indian or Alaska Native

□ Asian

□ Black or African American

□ Native Hawaiian or Other Pacific Islander

□ White

□ Another race (please fill in): ____________________

2d. Child 2’s age:____________

3a. What is your relationship to Child 3?

□ Primary parent or guardian

□ Grandparent

□ Other relative

□ Other non-relative

3b. Is Child 3 of Hispanic, Latino/a, or Spanish origin?

□ Yes

□ No

3c. What is Child 3’s race? Check all that apply.

□ American Indian or Alaska Native

□ Asian

□ Black or African American

□ Native Hawaiian or Other Pacific Islander

□ White

□ Another race (please fill in): ____________________

3d. Child 3’s age:____________

4a. What is your relationship to Child 4?

□ Primary parent or guardian

□ Grandparent

□ Other relative

□ Other non-relative

4b. Is Child 4 of Hispanic, Latino/a, or Spanish origin?

□ Yes

□ No

4c. What is Child 4’s race? Check all that apply.

□ American Indian or Alaska Native

□ Asian

□ Black or African American

□ Native Hawaiian or Other Pacific Islander

□ White

□ Another race (please fill in): ____________________

4d. Child 4’s age:____________

5. What are the main language(s) you use at home with your child(ren)?

Home language 1:

Home language 2:

5. Do you or others in your household usually speak to your child(ren) in languages other than the ones listed above? (This could include the languages grandparents, siblings, or other household members speak to your child.)

□ Yes

□ No

5. Which language(s) do you want your child’s provider to use with your child(ren)?

Preferred language 1:

Preferred language 2:

5. How and when do you prefer to communicate with your child’s provider? (circle all that apply):

• Method: Phone call Text Email In person (during drop off or pick up)

Other: ______

• Time of day: Morning Afternoon Evening

Part II

Instructions: For each statement, think about whether you’ve had the opportunity to discuss the topic with your child’s provider (for example, talking with them about activities or topics your child(ren) is interested in).

Then, choose…

• Agree if you have had the opportunity to discuss this topic with your child’s provider.

• Disagree if you have NOT had the opportunity to discuss this topic with your child’s provider.

• Not Sure if you don’t know or don’t remember.

• Not Applicable if the topic is not relevant to you (for example, if the question asks about summer break but your child does not go to child care over summer break).

Next, for each statement, think about how important it is to you to share your preferences about this topic with your child’s provider (for example, choose how important it is for you to talk to your child’s provider about using similar routines at home and in their care).

Then, choose …

• Very

• Somewhat

• Not at all

• Not something I want to discuss

Finally, write in any additional comments in the boxes provided, including specific things you want to talk about with your child’s provider on this topic (for example, “I want to talk about the kind of foods my child eats during care”).

	I’ve had opportunities to discuss the following with my child(ren)’s provider:				How important is it to you to discuss this topic with your child(ren)’s provider?
	Agree	Disagree	Not Sure	Not Applicable	Very	Somewhat	Not at all	Not something I want to discuss
A. Routines and Interests
1. My child(ren)’s home routines (for example, having quiet time in the morning or an after-school snack).	☐	☐	☐	☐	☐	☐	☐	☐
2. The ways our family responds to difficult behavior at home (for example, rules in my home, how we resolve conflicts at home).	☐	☐	☐	☐	☐	☐	☐	☐
3. My child(ren)’s dietary restrictions and/or food allergies.	☐	☐	☐	☐	☐	☐	☐	☐
4. Foods my child(ren) likes or dislikes, including foods we eat at home.	☐	☐	☐	☐	☐	☐	☐	☐
5. Activities and topics that my child(ren) is interested in.	☐	☐	☐	☐	☐	☐	☐	☐
6. Activities that my child(ren) likes to do at school or home (for example, sports, puzzles, dance, reading books).	☐	☐	☐	☐	☐	☐	☐	☐
7. How I want my child(ren) to interact with other children when my child(ren) is with my child’s provider (for example, if my child participates in outdoor activities with other children or if they spend time apart from their sibling).	☐	☐	☐	☐	☐	☐	☐	☐
Please add any additional thoughts or questions for your child’s provider related to Routines and Interests:
B. Family Background
1. The language(s) I want my child’s provider to use with my child(ren).	☐	☐	☐	☐	☐	☐	☐	☐
2. Cultural traditions, activities, and holidays that are important to our family (for example, eating a certain meal together, singing a song, or making holiday cards).	☐	☐	☐	☐	☐	☐	☐	☐
3. Behaviors that are important to our family (for example, kindness, patience, leadership, helping each other, independence).	☐	☐	☐	☐	☐	☐	☐	☐
4. How I want my child’s provider to plan activities or talk about aspects of my child(ren)’s identity (for example, reading books or sharing stories about my child’s culture, race, ethnicity, gender, or religion).	☐	☐	☐	☐	☐	☐	☐	☐
5. How I want my child’s provider to talk to my child(ren) about our family background or other personal experiences (for example, asking my child questions to learn more about our family or sharing stories about our ancestors).	☐	☐	☐	☐	☐	☐	☐	☐
Please add any additional thoughts or questions for your child’s provider related to Family Background:
C. Mental and Physical Health
1. The amount and type of physical activity I want for my child(ren) during care (for example, spending one hour per day outside).	☐	☐	☐	☐	☐	☐	☐	☐
2. How much screen time I want for my child(ren) (for example, how much time my child spends on an iPad and what types of activities they do).	☐	☐	☐	☐	☐	☐	☐	☐
3. My preferences for discussing news in the media and current events with my child(ren).	☐	☐	☐	☐	☐	☐	☐	☐
4. How I want my child’s provider to address any experiences related to bullying or discrimination that my child(ren) may face.	☐	☐	☐	☐	☐	☐	☐	☐
5. My preferences related to child(ren) getting healthy amounts of sleep.	☐	☐	☐	☐	☐	☐	☐	☐
Please add any additional thoughts or questions for your child’s provider related to Mental and Physical Health:
D. Connections to School and Community
1. How my child(ren) is doing in school (for example, struggling with writing, interested in science, having trouble making friends).	☐	☐	☐	☐	☐	☐	☐	☐
2. My preferences around completing schoolwork when my child(ren) is with my child’s provider (for example, how much time my child(ren) should spend on schoolwork while in provider’s care).	☐	☐	☐	☐	☐	☐	☐	☐
3. How I want my child’s provider to help my child(ren) learn over school breaks (for example, doing learning projects over the summer).	☐	☐	☐	☐	☐	☐	☐	☐
4. How I want my child’s provider to support my child(ren)’s special needs (for example, following the recommendations from my child’s teacher or a specialist).	☐	☐	☐	☐	☐	☐	☐	☐
5. The type of communication I would like my child’s provider to have with my child(ren)’s teacher(s)/school (for example, whether there are opportunities to talk to my child’s teacher or counselor).	☐	☐	☐	☐	☐	☐	☐	☐
6. My preferences around taking my child(ren) outside (for example, going for walks, to the playground, or to the library).	☐	☐	☐	☐	☐	☐	☐	☐
Please add any additional thoughts or questions for your child’s provider related to Connection to School and Community:

Thank you for completing the family questionnaire!

Please enter the time you finished this questionnaire. End Time: _______