SKCDC - Southern Kennebec Child Development Corporation

Care for ME Caregiver Questionnaire
If you have questions about this survey or need help filling it out,
please call: 1-866-638-7878

After filling out the survey, you can submit it electronically by clicking on the "Submit Survey" button, or you can print it out and mail it to us at:

Care for ME Program
99 Western Ave., Suite 6
Augusta, Maine 04330

First Name

Last Name

Business Name

Do you provide care:

In your home only

In the child's home only

In both your home and the child's home

Would you like referrals from the Care for ME program? Yes No

Would you like your rates made available to parents? Yes No

What is your physical address

Address Line 1

Address Line 2

City

State

Zip Code

What is your mailing address (if different)

Address Line 1

Address Line 2

City

State

Zip Code

County:

Maiden name or other aliases:

Please list all other adult household members and their dates of birth:

Name	Date of Birth

Primary Telephone #

Other Telephone #

Fax # Email:

Website:

Social Security #: Drivers License #:

10.

Do you have openings in your
child care?

Yes

If yes, how many?

11.

What ages of children will you care for?

Youngest age: Oldest age:

12.

What is your date of birth?

13.

Are you willing to provide
transportation for children?

Yes

14.

Are you within walking distance to any schools? Please list:

15.

Please list all the languages you speak (including American sign language)

16.

What time does your child care open?
What time does it close?

17.

What days are you open (check all that apply):

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

18.

Do you provide:

Full time care

Part time care

Both full and part time care

Drop in care

Temporary/emergency care

24 hour care

Before school care

After school care

Care on holidays

Care for people with
rotating schedules

19.

Please fill in your rates (prices you charge for child care):

Age Group	Age Range	Full-time Rate	Part-time Rate	Hourly Rate
Infant	0 to- 12 months
Toddler	13 months - 3 years
Preschool	3 years - 5 years
Before/After school only	5+ years
School age	summer and vacation, 5+ years

20.

Odd hour care fees (care between 6 p.m. & 6 a.m. or weekends)
please list if applicable:

Age Group	Age Range	Full-time Rate	Part-time Rate	Hourly Rate
Infant	0 to- 12 months
Toddler	13 months - 3 years
Preschool	3 years - 5 years
Before/After school only	5+ years
School age	summer and vacation, 5+ years

21.

Do you have any of these extra fees (please check all that apply):

Late fee

Field trip fee

One time registration

Annual registration

Preschool

Drop in

Lesson(s)

Meals

Other: Please list:

22.

Do you provide Respite care?

Yes

Environment

23.

Please check all that apply to your child care:

Smoking

Non-smoking

Outdoor play area

Fenced yard

Wading pool

Swimming pool

Dog

Cat

Caged pet(s)

No indoor pets

No pets

Faith based
programming

Lead safe home

Near city/public park

Provider willing
to transport

Urban setting

Rural setting

Meals

24.

Please check all that you are willing to provide:

Breakfast

Morning snack

Lunch

Afternoon snack

Supper

Current USDA food
program participant

Formula provided
by parent

Formula provided
by caregiver

Meals provided
by parents

Diapers provided
by caregiver

Acceptance

25.

Financial Assistance (subsidy payments from Aspire, Voucher, etc.)

I will accept

I will not accept

Policies

26.

Please check all that apply:

Written contract

Written handbook

Multi-child discount

Caregiver has paid
vacations

No paid vacations
for caregiver

Caregiver has paid
holidays

No paid holidays for
caregivers

Parents pay when
they take vacation

Parents pay when
child is sick

Parents do not pay
when child is sick

Special Skills

27.

Please check all that apply:

Sports/recreation
experience

Foster parent

Social work
experience

Special education
experience

Lifeguard

Music experience

Current CNA license

Other:

Safety

28.

Please check all that apply:

CPR current

First aid current

Health related
degree

Liability insurance
(not homeowners)

Video monitor
on site

Audio monitor
on site

SIDS monitor on site

Password/key
admittance

Fire detector
on site

Carbon monoxide
monitor on site

Special Needs Experience

29.

Please check all that you have training or experience in:

Speech and language
delays

Physical disabilities

Asthma

Visual impairments

Hearing impairments

Tube feeding

Autism/PDD

Developmental
delays

Aspbergers

Mental retardation

Sensory integration
disorder

Food allergies

HIV/Hepatitis B

Epi-Pen

Social/emotional

Diabetes

Cleft lip/palate

Cerebral palsy

Seizures (other than
febrile)

ADD/ADHD

Other mental
health

Behavioral issues

Cystic Fibrosis

Dyslexia

Child on medication

Caregiver willing to
dispense medication

Home is wheel
chair accessible

Willing to take
specialized training

Maine Roads to
Quality inclusion
training

Maine Roads to
Quality social /
emotional training

Other

30.

How many hours of training have you had in the last year?

What kind of training was it?

31.

Have you had college courses for credit?

Yes

If Yes, please list college and course(s)

32.

Are you on the Maine Roads to Quality Registry?

Yes

33.

How many years experience have you had caring for other peoples children?

What kind of experience was that? (please check all that apply):

Family child care

Center based care

Nanny

School system

34.

Please list your education level (High school diploma/GED; College - degree type)

35.

Please list all child care organizations you belong to:

36.

Do you want referrals from your local Resource
Development Center?

Yes

Activities

Please check all the activities you offer in your program:

Religious

Music & movement

Arts and crafts

Cooking

Story time

Preschool
Curriculum

Field trips

Circle time

Cultural activities

Other:

Optional Questions

The next set of questions is for statistics only, this information
will not be given out, it is only used to track legal-exempt care
in the State of Maine and the qualities of legal-exempt care.
You are not obligated to answer the questions below.

37.

Please check where your child care is located:

Your home

Your apartment

Your townhouse

Your mobile home

Your duplex

In child's home

38.

Please check which wage category applies to you:

I make under $15,000 per year
I make between $15-35,000 per year
I make over $35,000 per year
I do not wish to disclose this information
I do not know this information

39.

Insurance Statistics (please check all that apply):

I have my own health
insurance

I have health insurance
with my spouse

I have my own dental
insurance

I have dental insurance
with my spouse

I do not have health
insurance at all

I am on state health
insurance

I do not have dental
insurance at all

I have my own
retirement plan

I have a retirement plan
with my spouse

I have paid sick time

40.

What is your race or ethnicity?

Thank you for taking the time to fill out the Care for ME Caregiver Questionnaire.

Care for ME
A Joint Project of Southern Kennebec
Child Development Corporation
and the Maine Department of Health and Human Services

Care for ME Caregiver Questionnaire If you have questions about this survey or need help filling it out, please call: 1-866-638-7878

Care for ME Caregiver Questionnaire
If you have questions about this survey or need help filling it out,
please call: 1-866-638-7878