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1.
Do you live in Stamford?
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2.
How long have you lived in Stamford?
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3.
What is your Zip Code?
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4.
How old are you?
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5.
Are you a Man or a Woman?
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6.
What do you consider to be your race or ethnicity
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7.
Are you currently employed?
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8.
If you are currently employed, what field do you work in? If you are unemployed, please skip this question.
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9.
What is your work status? Are you:
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10.
How many hours a week do you usually work?
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11.
What language or languages do you speak in your home?
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12.
What is your marital status? Are you:
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13.
Were you born in the United States?
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14.
Are you a member, or part of, a religious or faith community?
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15.
Which religious or faith tradition do you follow or practice? Check all that apply.
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16.
When you are at work, who usually takes care of your children? Please check all that apply.
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17.
If your child goes to preschool, is the school accredited?
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18.
If you send your child to a family day care, or day care home, is it accredited?
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19.
How many children between the ages of 10 and 18 live in your house?
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20.
How many children between the ages of six and nine live in your house?
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21.
Do you attend school functions such as open houses and parent-teacher conferences?
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22.
If you do not attend school functions such as open houses and parent-teacher conferences, please tell us why.
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23.
Are you an active member of your Parent-Teacher Organization (PTO)?
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24.
If you are not an active member of your Parent-Teacher Organization (PTO) and you do have school-aged children, please tell us why.
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25.
What kind of activities that have been organized by your child's school Parent-Teacher Organization (PTO) have you attended? If this does not apply to you, please leave blank.
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26.
What type of school does your child or children attend? Check all that apply.
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27.
If you have one or more school age children, what school does your youngest child attend? Please name.
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28.
What kinds of recreation activities does your youngest child participate in? Check all that apply:
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29.
Is there a particular clinic, health center, hospital, doctor’s office, or other place that your family uses for your childrens health care?
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30.
When you go to the doctor for your child, does the doctor or nurse explain things to you in a way that you can understand?
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31.
Do you have a child or children with special needs, delays, or disabilities living in your home?
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32.
What is your household's income?
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33.
Do you have relatives, friends, or others nearby such as a counselor or minister who you can turn to for help or support when you need it?
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34.
Have you or anyone in your family ever tried to find help, information or other support for a child or family in Stamford?
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35.
If you answered yes to the previous question, please tell us where you went for help.
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36.
If you did receive help, information or other support from one of the above, were you able to get as much help as you needed?
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37.
Have you ever been to an educational, social, or human services agency for help?
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38.
How do you find out about services or resources for your children or family? Check all that apply:
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39.
When you went to an agency for help, were they able to refer you to another agency which might also be able to help you further?
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40.
What are your most important sources of emotional support or advice (such as sharing feelings, advice on dealing with problems and so on)? Check all that apply:
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