The Orange County Partnership for Young Children is conducting an evaluation project in cooperation with the Frank Porter Graham Child Development Center to assess the "school readiness" of a sample of young children in child care centers in Orange County who are entering kindergarten in the Fall of 1997.

Children will be identified who are entering kindergarten and have been exposed to multiple Smart Start efforts in their child care center for at least two years. The names of child care centers and children will be kept confidential and will not be associated with study findings. (The following information was obtained from directors of participating child care centers and parents of study children).

1. Name of child: _____________________

2. Child’s date of birth: ________________

3. Initial enrollment date: ______________

4. Name of elementary school child will likely attend: _________________________

5. Child’s previous child care experience:

7. Phone number: ________________________________

8. Address: ____________________________

                                    ______________________

                                     ______________________

9. Residential area:     North Orange County ____

                                      Chapel Hill ____

                                      Carrboro ____

                                      Hillsborough ____

                                     Other location _________________________

10. Child’s race/ethnicity:

                                     Caucasian ____

                                     African-American ____

                                     Hispanic/Latino ____

                                     Asian ____

                                     Other ____________________

11. Chronic health problems (If yes, please list): Yes ____ No ____

_______________________________________________________________________________

_______________________________________________________________________________

12. Other identified special needs (If yes, please list): Yes ____ No ____

_______________________________________________________________________________

_______________________________________________________________________________

13. Family structure (according to head of household):

                                     Single parent (under 18) ____
                                     Single parent (over 18) ____
                                     Both parents (under 18) ____
                                     Both parents (over 18) ____
                                     Grandparents ____
                                     Foster parents ____
                                     Other guardian ____

14. Family size (total number of family members living in the home):

                                     2 persons ____
                                     3 "" ____
                                     4 "" ____
                                     5 "" ____
                                     More than 5 ____

15. Receiving child care subsidy: Yes ____ No ____
(If yes, please check the box that indicates which agency provides subsidy):

                                         DCSA ____                 DSS ____

 
That is all the demographic data that was collected from your child’s center.

Would you mind if I ask 3 more questions about you, the parent? You may choose not to answer any particular question by just telling me. Yes ____ No ____

1. What is the income range for your family? (total family income):

                                            Below 10,000 ____
                                            10,000 – 15,000 ____
                                            15,000 – 20,000 ____
                                            20,000 – 25,000 ____
                                            25,000 – 30,000 ____
                                            30,000 – 35,000 ____
                                            35,000 – 40,000 ____
                                            Above 40,000 ____

2. What is your birth date? ___________________

3. What is the highest grade level that you have completed? ___________________
 
 

The last three questions are about your child’s experience in child care and the services he/she has received outside the child care center.

1. What type of health screening or other services has your child received in the community?

2. Do you have any suggestions about how your child could have had a better experience in child care?
 

3. Other comments: