Please take notice that it is imperative this questionnaire be submitted in confidentiality & directly,from the child’s daycare to the school. Any document received on behalf of the parents will be refused. Deadline: March 2, 2018

Fax Number: 514 353-0408

Mailing address:ÉcoleAlbatros

6440, boul. Les Galeries d’Anjou

Anjou, Québec

H1M 1W2

Tél: 514 353-5131

Email:

Child’s identification

Name and family name: ______

Child’s gender: M ______F ______child’s age: ______

DAYCARE INFORMATION

Daycare or CPE name: ______

Address: ______

______

Telephone: ______

Type of daycare: Daycare centre______Home daycare ______

Name of daycare worker (educator): ______

Rest assured that all the information disclosed in this questionnaire will remain confidential.

Please complete the questionnaire in order to offer the most accurate portrait of the child.

If you have any questions regarding this form, please contact Albatros School.

Thank you for the time spent during this process.
Daycare, CPE questionnaire

  1. What are the child’s strengths and challenges?

______

  1. Does this child present any characteristics that require special attention?

______

  1. Describe the relationship you have with the family (interactions, collaboration).

______

  1. Describe the involvement of the family in the child’s life and at the daycare.

______

  1. Describe the parents’ expectations towards the child care setting, the staff and their child.

______

  1. Describe the parents’ compliance with the operating rules of the daycare and staff.

______

  1. Knowing that analternative schoolrequires greatparental involvementand a certainlevel of autonomyon behalf of the child,do you thinkour school isa suitable option forthis family?Explain.

______

Other comments

  1. Do you haveother thingsto sharethat might be relevantto help usproperly evaluatethis application, regarding eitherthechild, the parents, the interaction with thedaycare staff, etc.?

______

Daycare questionnaire 1

For questions 9 to 16, check all answers that describe the child.

Daycare questionnaire 1

Daycare questionnaire 1

  1. Once the child has understood the instructions of a task, how does he proceed?
  • The child performs the task independently
  • The child needs help to start the task, but manages to get by afterwards
  • The child needs to have the instructions repeated often throughout the entire duration of the task
  • The child often refuses to participate in activities
  • Other (explain) ______

Comments: ______

______

Daycare questionnaire 1

  1. How does the child react when confronted with a challenge?

Daycare questionnaire 1

  • Gives up, gets discouraged
  • Takes on another activity
  • Asks for help
  • Accepts help from another person
  • Cries
  • Gets upset, angry
  • Attempts several times to find a solution
  • Starts over until success is achieved
  • Perceives difficulties as a failure
  • Asks for help from the adult even if help is not truly required
  • Other (explain) ______

Daycare questionnaire 1

Comments: ______

______

Daycare questionnaire 1

  1. During periods of free playtime, the child:
  • Needs the presence of an adult in order to work well
  • Chooses a game without being asked
  • Often changes games
  • Waits to be given a game
  • Selects a game based on the choices of others
  • Other (explain) ______

Comments: ______

______

  1. In terms of social skills, how would you describe his relationships with other children?

Daycare questionnaire 1

  • Conflictual relationships
  • Harmonious relationships
  • Isolated child/ solitary
  • Opposing child
  • Sociable child
  • Respectful child
  • Confident child
  • Wary child
  • Scapegoat child
  • Cooperative child
  • Positive leader child
  • Negative leader child
  • Reserved child
  • Impressionable child
  • Other (explain) ______

Daycare questionnaire 1

Comments:______

______

  1. How would you describe the child’s relationships withadults?

Daycare questionnaire 1

  • Hostile relationships
  • Harmonious relationships
  • Wary Child
  • Opposing child
  • Respectful child
  • Pervasive child
  • Adult dependent
  • Collaborative and helpful child
  • Reserved child
  • Other (explain)______

Daycare questionnaire 1

Daycare questionnaire 1

Comments: ______

______

  1. When there is a conflict, the child …

Daycare questionnaire 1

  • Listens to the other person
  • Argues
  • Is never wrong
  • Cries
  • Is grumpy
  • Blames others
  • Shoves, reacts aggressively/ violently
  • Comes to an adult for help to resolve the conflict
  • Comes to an adult to complain about others
  • Often yields
  • Never complains
  • Offers solutions
  • Withdraws and isolates himself
  • Communicates with the other child in a clear and respectful manner
  • Other (explain) ______

Daycare questionnaire 1

Comments: ______

______

  1. Child’s attitude towards learning

Daycare questionnaire 1

  • He enjoys learning
  • He knows his limits and uses his strengths
  • He is creative
  • He is curious, asks questions
  • He shows littleinvestment
  • He observes
  • He enjoys taking on challenges
  • He seeks to be the best (competitive)
  • Other (explain)______

Daycare questionnaire 1

Comments: ______

______

  1. During exchanges and talks, the child...
  • Willingly expresses his opinion, contributes with ideas
  • Remains alert and engaged
  • Offers his opinion only if asked to do so
  • Has reservations, refuses to speak
  • Waits for his turn to speak
  • Is often off-topic
  • Takes into account the other child and his point of view
  • Shows little interest, looks away, is distracted
  • Enjoys giving his opinion but shows no interest for the opinions of others

Comments:______

Thank you for your cooperation.

Daycare questionnaire 1