2023/2024 Support for Children & Families–Parent/Caregiver Survey Demographic Information: Please share some information about yourself. Please be assured that all information is confidential and will be used only for statistical purposes in combination with other data.All questions with a “ * ” are required. Child First Name and Last Name Initial (ex. John B.) * Parent/Caregiver Gender * Select Male Female Transgender Non-binary/Genderfluid/Prefer to self-describe Prefer not to say Parent/Caregiver Age * Select 0-3 4-5 6-11 12-17 18-24 25-34 35-44 45-54 55-64 65-74 75-84 85-94 95 & Over Prefer not to say How would you describe yourself? * Select One African American / Black Asian Caucasian / White Hispanic / Latino Middle Eastern Multi-racial Native American Native Hawaiian / Pacific Islander Other Prefer not to say Household Income * $0 - $9,999 $10,000 - $14,999 $15,000 - $24,999 $25,000 - $36,999 $37,000 - $49,999 $50,000 - $74,999 $75,000 or more Free and Reduced Priced Lunch Prefer not to say What is your Zip Code? * Are you or have you ever been a member of the Armed Forces? * Select Yes No Prefer not to say What is the primary Language spoken in the home? Select English Spanish Hmong ASL N/A Other Directions: There are 2 sections in this survey; please answer each question as indicated below: Section 1. Caregiving/parenting Skills – check the box that best describes how much you agree with each of the following statements. I learned more positive caregiver/parenting skills. * Select Not at All Very Little Somewhat Very Much N/A I use or will use the skills I learned. * Select Not at All Very Little Somewhat Very Much N/A Since coming to this program, the relationship with my child(ren) has improved in: communication. * Select Not at All Very Little Somewhat Very Much N/A Since coming to this program, the relationship with my child(ren) has improved in: physical. * Select Not at All Very Little Somewhat Very Much N/A Since coming to this program, the relationship with my child(ren) has improved in: emotional/bonding. * Select Not at All Very Little Somewhat Very Much N/A I am better able to control my anger. * Select Not at All Very Little Somewhat Very Much N/A Section 2. Stress Reduction – check the box that best describes how much you agree with each of the following statements. I learned positive ways to deal with stress. * Select Not at All Very Little Somewhat Very Much I know of people I can talk to or resources I can use when I have needs. * Select Not at All Very Little Somewhat Very Much I interact with family and friends in a more positive way. * Select Not at All Very Little Somewhat Very Much My overall health has improved. * Select Not at All Very Little Somewhat Very Much My stress has decreased. * Select Not at All Very Little Somewhat Very Much Please select the responses that best describes how much you agree with each of the statements and provide additional comments. 1. My child has improved his/her communication skills as a result of services received through this program. * Select Not at All Very Little Somewhat Very Much N/A 2. I feel that I am better able to make decisions pertaining to my child's hearing loss, communication, & development as a result of services received through this program. * Select Not at All Very Little Somewhat Very Much N/A 3. My favorite part of the program for my family is… 4. One thing we benefited the most from this program is... 5. Something I would change/add to make the program better would be… 6. I have participated in the following activities: Auditory-Verbal Therapy Speech-Language Therapy ConnectHEAR TeleIntervention Services Toddler Communication Group HEAR Wisconsin Fundraiser Activities Home Visit Day care visits Brewer Game Fall Fest Winter Wonderland Brunch FamilyLink Events 7. Would you be willing to be a resource for another parent? Select Yes No 8. If you’ve had a positive experience, would you be willing to help promote HEAR WI by sharing your experience (with)…. an Administrator a member of HEAR Wisconsin Board at a future HEAR Wisconsin event by writing a comment or story that could be published Other If you answered yes to question #7 or #8, please fill out the following information: Name First Name Last Name Email Please add any additional comments or suggestions below: Thank you!
