1. Share with me the zip code in which you live. {Indicate one only}

27101 / 27103 / 27104 / 27105 / 27106 / 27107 / 27012 / 27127 / 27051 / 27052
Other / 27009 / 27050 / 27019 / 27157 / 27045 / 27284 / 27023
City / State

2. How would you classify your profession/occupation, what is your line of work?

Legal / Management/Business / Homemaker / Computer Professional / Clergy
Education / Self-Employed / Engineer/Technology / Service/Retail Industry / Mental Health
Unemployed / Scientist/Researcher / Student / Human Service / Government
Retired / Disabled / Medical Profession / Manufacturing / Other

3. Please share thehighest education level you have completed.

high school
{or GED} / Certificate / 2-Year / 4-Year / Master’s / Doctorate / Other

4. What ethnic/racial group do you best identify with?

African-American/Black / Caucasian/White / Indian {Native American} / Latino/Hispanic
Asian / African / Bi-Racial / Other

5. What is your age range/sex?

21 - 25 / 26 - 35 / 36 - 45 / 46 - 55 / 56 - 65 / 66 +
male / male / male / male / male / male
female / female / female / female / female / female

6. What is your current family status?

Foster Family Care / Respite only Foster Care / Relative or Kinship Home Care / Therapeutic
Care / Adoptive Family Care / Foster/Adopt Family

7. For adoptive parents ONLY-following your adoption, did you continue as a foster family and continue to accept children into your home as foster placements?

Yes / No

8. Tell me about your journey… How did you initially become interested in being a Foster, Adoptive or Relative Caregiver?

Newspaper Advertisement / Internet Advertisement / Relationship with a foster /adoptive family
Radio Advertisement / Billboard advertisement / Family Situation/Circumstances
Foster family recommendation / Community Presentation / Fair {Dixie Classic, Health Fair, YMCA Fair,
Community Fair}
Other

9. What could the agency have done to help you complete the application process?

Returned call from the agency / Application available on-line / Interest meetings held at different times
MAPP/Training sessions held at different times / Staffto answer questions / Face to face / home visit options at different times
Information in different languages / Other

10. What could the agency have done to help you complete the licensure/adoptive process?

Incentives for completion / Quicker response times from the agency / Meal to the families attending MAPP training
Cover initial expenses {fire inspection, first aid & CPR} / Child care for MAPP classes {in addition to panel night}
Other

11. Did you get the age range of child you initiallywanted? Yes or No

What age range and sexwere you seeking?

Infant – 4 years / 5 – 10 years / 11 – 13 years / 14 – 18 years / 18-21 years
male / male / male / male / male
female / female / female / female / female

12. If you checked you did not want a teen, what would encourage you to consider a teenager?

Increased financial incentive / Specialized training / Education regarding resources for teenagers / Additional Support
Other

13. Why do you continue to foster? Why is this your calling, your passion?

Give back to the community / Love children / Would like to continue to expand my family by fostering/adopting
Strong desire to preserve sibling groups / Empty nest, want to continue caregiving / Not able to birth children
Other

14. What could the agency do to improve our communication/correspondence with you?

Use of E-mail / Direct access to a live person / Having bi-lingual staff / On-line question / chat
Other

15. What type of training and support, if any, do you feel you need or needed inaddition to MAPP training?

Shared parenting / Community resources
Strengths based perspective / Attachment/Loss issues
Foster/Adopting of Teens / Cultural diversity
Child development training / Fostering/Adopting an bused child {physical or sexual}
Parenting a child of a different race / Foster/adoptive family support group
Support groups for kids in Foster Care or Adopted / Other

16. What incentives would encourage you to refer other Foster/Adoptive families?

Financial / Public recognition {newsletter, picnic, newspaper} / Other

17. What ways are you willing, if any, to volunteer your time to help locate new Foster/Adoptive families?

MAPP co-facilitator / Speaking engagements / Office help, preparation for MAPP groups
Panel Speaker / Health Fairs / Community Presentations
Other

18. What suggestions do you have that can improve the foster/adoption services?

*To be eligible for the gift card drawing, you must complete the following info:

Name / Best Phone # to use
Address / E-mail Address

THANK YOU for completing this survey and for making a positive difference in our community!

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