About you
First name:
Last name:
House name or number: Postcode:
Date of Birth:
Gender:
Status:
How would you describe your ethnic
origin? e.g. White British, Pakistani, African, Carribean, Bangladeshi,
Kashmiri or Dual Heritage etc.
Employment status:
--- Please choose ---
Full time
Part time
Studying/Training
Self employed
Full time parent
Maternity leave
Not working
Other
if 'other' please state:
Approximately what was your gross family income last year?
Childcare issues
Please tick the age groups you have children in:
Expecting child newborn - 18 months 18 months - 3 years
3 years - 5 years 5 years - 11 years 11 years - 16 years
Do any of your children have any additional needs?
If yes, which Additional Educational Needs have been identified? (tick all that apply)
Behaviour, emotional and social development Cognition and learning
Physical / Sensory Communication and Interaction
Over the past 12 months have you needed anyone (including family or friends) to take care of your children?
If yes, for what reason?
Employment Training/Study Socialisation (child) Socialisation (parent)
Back-up care/sickness (child or parent) Early Education (child) Other
Tick all the boxes of when care was needed:
Full day care Half day care / sessional care Before school After School
Holiday care (full day) Holiday care (half day) Night or weekend care
Other: please explain
Did you get all the childcare you needed in the past 12 months?
Tick all the ways in which care was provided for your children:
Formal
Before/After School Childminder Day Nursery Home Childcarer
Holiday Club Playgroup Nanny Nursery School
Informal
In relatives home Relative in child's home Parent Toddler Group In non-relatives home
Non-relative in child's home Other :
please specify
If you couldn't get all of the childcare needed, please explain why. (tick all that apply)
Not satisfied with the quality of the provision
The cost of care was too high
I work unsociable hours and care wasn't available when I needed it
No childcare provision/vacancies in the area required
My child has special needs that couldn't be accommodated
Setting unable to cater for child due to age
Unable to meet transport needs for child
Other (please explain )
Please rate the following factors on their importance to you when choosing childcare:
Finding care that meets my hours
--- please choose ---
1 - Not important
2
3
4
5 - Very important
Being able to afford the care I want
--- please choose ---
1 - Not important
2
3
4
5 - Very important
Reliability of caregiver(s)
--- please choose ---
1 - Not important
2
3
4
5 - Very important
Quality of childcare environment
--- please choose ---
1 - Not important
2
3
4
5 - Very important
Finding a convenient location
--- please choose ---
1 - Not important
2
3
4
5 - Very important
Safety Issues
--- please choose ---
1 - Not important
2
3
4
5 - Very important
Experience & knowledge of AEN
--- please choose ---
1 - Not important
2
3
4
5 - Very important
Please tell us which of the above factors you regard as the MOST important
--- please choose ---
Finding care that meets my hours
Being able to afford the care I want
Reliability of caregiver(s)
Quality of childcare environment
Finding a convenient location
Safety Issues
Experience & knowledge of AEN
Are you aware of Oldham Family Information Service?
Tick all of the following types of childcare you may require in the near future:
Care for child with special needs Day Nursery Childminder Holiday care
Before school care After school care Playgroup
In the near future, what other factors might influence your choice of childcare:
Bilingual support Care close to home Care close to work Care for early mornings
Weekend care Care for sick child/ren Emergency/backup care Care for evenings/nights
24 hour care Specialist care for child with special needs
Other (please specify )
When in the future might you need childcare?
Immediately 3-6 months 6-12 months 12 months or more
For the following childcare grant, funding and benefits, please tick any you have heard of and any you currently access:
Nursery Education Grant
Heard of Currently access
Childcare element of the Working Tax Credit (paying towards childcare costs)
Heard of Currently access
Childcare Vouchers via your employer
Heard of Currently access
Disability Living Allowance
Heard of Currently access
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