Child Care Setting Recruitment Form

O MB No.: 0970-0392

Expiration Date: 09-30-2013

Quality of Caregiver-Child Interactions for Infants and Toddlers (Q-CCIIT):
Child Care Setting Questionnaire

Draft

October 26, 2011

Mathematica ID: | | | | | | | | |
Interviewer ID: | | | | | |
Date of Interview:	| | | / | | | / | 2 | 0 | | | Month Day Year

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 0970-0392. The time required to complete this collection of information is estimated to average 10 minutes, including the time to review instructions, search existing data resources, gather the data needed and complete and review the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Amy Madigan at 202-401-5143 or Amy.Madigan@acf.hhs.gov and reference the OMB Control Number 0970-0392. Note: Please do not return the completed questionnaire to this address.

A1. Number of Classrooms with children 36 months or younger

| | | classrooms

A2. Approximate number of eligible children per classroom

A2a. Age ranges for eligible classrooms

A3. What languages are spoken in these classrooms?

MARK ALL THAT APPLY

1 □ English

2 □ Spanish

3 □ Other (please specify)

A3a. For classrooms that speak languages other than English, what languages are spoken in these classrooms? Is it . . .

MARK ALL THAT APPLY

1 □ Mostly English/Spanish,

2 □ 1/2 English, 1/2 Other language, or

3 □ Mostly another language?

CHECK CHILD AGE CUTOFF DATE AND LANGUAGE. IF OKAY, GO TO A4. IF NOT, THANK AND END.

A4. AGREE TO PARTICIPATE

1 □ Yes

0 □ No

A5. Contact info for SPP, phone, email, address

Name of setting

Name of Gatekeeper

Name of SPP

| | | | - | | | | - | | | | |

AREA CODE NUMBER

STREET

CITY STATE ZIP

EMAIL

A6. Best means of communication

1 □ Phone

2 □ Email

A7. Network

A8. Year that the business or program was established

| | | | | year

A9. Hours of operation

| | | : | | | TO | | | : | | |

am/pm am/pm

1 □ Monday

2 □ Tuesday

3 □ Wednesday

4 □ Thursday

5 □ Friday

A10. Dates children are not present during proposed observation period

A11. CONTINUE TO SECTION B OR SCHEDULE NEXT CALL.

IF NEW CALL: DATE: | | | / | | | / | 2 | 0 | | |

FOR CLASSROOMS WITH CHILDREN UNDER 36 MONTHS

B1. What is this classroom called?

B2. How many children are currently enrolled in this classroom (regardless of age)?

| | | children

B2a. Number of eligible children in classroom

| | | children

B3. What is the age range of this classroom? IF MIX, GO TO B4, IF NOT, GO TO B5

| | | months TO | | | months

B4. Please provide the date of birth for each child in this classroom.

CHILD	DATE OF BIRTH	CHILD	DATE OF BIRTH	CHILD	DATE OF BIRTH
1	| | | / | | | / | | |	6	| | | / | | | / | | |	11	| | | / | | | / | | |
2	| | | / | | | / | | |	7	| | | / | | | / | | |	12	| | | / | | | / | | |
3	| | | / | | | / | | |	8	| | | / | | | / | | |	13	| | | / | | | / | | |
4	| | | / | | | / | | |	9	| | | / | | | / | | |	14	| | | / | | | / | | |
5	| | | / | | | / | | |	10	| | | / | | | / | | |	15	| | | / | | | / | | |

B5. What languages do the caregivers speak in this classroom?

MARK ALL THAT APPLY

1 □ English

2 □ Spanish

3 □ Other (please specify)

b6. If other than English, is it . . .

MARK ALL THAT APPLY

1 □ Mostly English/Spanish

2 □ 1/2 English, 1/2 Other language, or

3 □ Mostly another language?

b7. For this classroom, what time do most children arrive in the morning?

| | | : | | |

b8. What time is . . .

B8a. Breakfast	B8b. Morning Snack	B8c. Lunch
| | | : | | |	| | | : | | |	| | | : | | |

b9. Are there any times when the children are not with their regular caregivers in the morning (e.g., music)?

B10. How many teachers work in this classroom 4 or more hours a day?

| | | teachers

B11. And how many teachers, classroom aides, or volunteers work in this classroom less than 4 hours a day?

| | | number

B12. Which best describes how the workload is shared among caregivers in this classroom?

MARK ONLY ONE

n/a □ CODE AS N/A IF ONLY ONE CAREGIVER

1 □ Caregivers share responsibility equally for all children,

2 □ Individual caregivers are assigned primary responsibility for small groups of children,

3 □ A lead caregiver is primarily responsible for the children while the assistant supports the lead caregiver, or

4 □ Some other arrangement? (please specify)

AFTER SPEAKING ABOUT ALL CLASSROOMS:

What percentage of children in this child care setting receive free or reduced food or other subsidies related to participation in this child care setting?

| | | | percent

C1. Confirm hours of operation

| | | : | | | TO | | | : | | |

am/pm am/pm

1 □ Monday

2 □ Tuesday

3 □ Wednesday

4 □ Thursday

5 □ Friday

C2. Confirm dates children are not present during observation period

C3. Observation date/time

DATE START TIME CLASSROOM NAME

| | | / | | | / | 2 | 0 | 1 | 1 | | | | : | | | AM

NOTES:

DATE START TIME CLASSROOM NAME

| | | / | | | / | 2 | 0 | 1 | 1 | | | | : | | | AM

NOTES:

DATE START TIME CLASSROOM NAME

| | | / | | | / | 2 | 0 | 1 | 1 | | | | : | | | AM

NOTES:

DATE START TIME CLASSROOM NAME

| | | / | | | / | 2 | 0 | 1 | 1 | | | | : | | | AM

NOTES:

Thank you very much for your time.