Appendix B
Lesbian and Gay Child Care Task Force Needs Assessment
for Lesbian, Gay, Bisexual and Transgender Families

CODE ________

Confidential Information Form


Please check the box(es) that apply:
  1. Your current age: Under 21 21-30 31-40 41-50 50 or older

  2. Male Female

  3. Lesbian Gay Bisexual Transgender Heterosexual

  4. If you are a LGBT parent are you out to your child care provider? Yes No

  5. If you are a LGBT child care provider are you out to your staff and the families you serve? Yes No

  6. What is your ethnicity? ______________________________________________

  7. If you are a child care provider what are the ethnic groups you serve? _________


  8. Please describe your family structure: Co-Parent Single Parent Foster Care Family

  9. Blended Family (please describe) _____________________________________

  10. What is your yearly family income? $25,000 or under $26,000-40,000 $40,000-60,000 $60,000 or over

  11. Who takes care of your child? family member relative friend family home provider child care center other _______________________

  12. What 3 steps did you use in selecting your child's care provider?




Thank you very much for your time and willingness to be a significant part of a great effort to improve the quality of child care for all children-especially children of lesbian, gay, bisexual and transgender families.

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