*
*
*
First Name
Last Name
Month Requested Care
*
How would you rate the
quality of consultation
you obtained from our specialist?
High Quality
Fair Quality
Poor Quality
*
How would you rate the
quality of information
you obtained from our specialist?
High Quality
Fair Quality
Poor Quality
*
How long did it take you to receive the list of providers we sent you?
24 Hours
3 or fewer days
4-5 days
more than 5 days
*
Did the specialist or information provided help you
learn more about
the characteristics of
quality child care?
Yes
No
*
Did the specialist or information you receive
increase
your
knowledge
about different child
care options
?
Yes
No
*
Did the specialist or information provided increase your
knowledge about financial services
and other financial resource options?
Yes
No
N/A
*
Was the resources and/or referral you received helpful in helping you
find appropriate care?
Even if the one you choose was not on the referral list sent to you.
Yes
No
*
What type of care did you choose?
family
group
center
aide or relative
none
in home
*
Were there any problems in finding child care?
cost
location
quality
schedule
none
program
no openings
other
*
How would you rate our services over all?
Very Good
Good
Fair
Poor
Very Poor
*
Would you use 4C again?
Yes
No
*
Would you recommend us to others?
Yes
No
*
Did you find the website and or internet user friendly?
Yes
No
*
How might we improve our services?
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