© Coastal Enterprises, Inc.
AF 02/24
Are you willing to be contacted for future research projects? Select Yes or No
Have you ever had any training about child abuse? Select Yes or No
What is your gender? Select Male, Female, Gender non-confirming, or other
What is your ethnicity? Select Hispanic or Latino or Non-Hispanic or Latino
What is your race? Check as many boxes as applicable: American Indian or Alaska Native,
Black or African American, Native Hawaiian or Pacific Islander, White/Caucasian, Asian,
Other
How old are you? Select your age range: Less than 18, 18-29, 30-44, More than 44
How religious would you say you are? Select Extremely unreligious, Unreligious, Somewhat
unreligious, Neutral, Somewhat religious, Religious, Extremely religious, Prefer not to
answer
What is your marital status? Select Single, Married or cohabitating, Separated or divorced,
Widowed
Are you a parent/guardian of a child? Select Yes or No
If Yes, How old is your youngest child? Select 5 years old or younger, 6-17 years old,
Older than 17 years
What is your highest level of education? Select 8
th
Grade, High School Diploma/GED, CDA,
Associate’s Degree, Bachelor’s Degree, Graduate degree and/or beyond, No Formal
Education
Do you have any formal training in early childhood education? Select Yes or No
Which of the following best describes your primary job responsibilities? Select Assistant
Director, Admin, Teacher, Teacher’s Aide, Volunteer, Intern, Cook, Maintenance,
Administrator/Hands-On/Support
Are you a program owner or director? Select Yes or No
If Yes, indicate the number of children currently enrolled in your program: 0-5, 6-10, 11-
25, More than 25
On what basis are you currently employed? Select Volunteer, Paid Full-Time, Paid Part-
Time, Paid Seasonal, Paid Substitute
Including this year, how many years have you worked as a child care provider? Select Less
than 1, 1-2, 3-5, 6-10, 11-15, More than 15
Including this year, how many years have you worked at your current workplace? Select
Less than 1, 1-2, 3-5, 6-10, 11-15, More than 15
License number of the child care program where you work or volunteer? Enter your licensed
number or if you don’t yet have a license number enter 555555
Program Name? Enter name of the child care program you work at or enter TBD (to be
determined)