Food Safety for Daycare Providers - Pre-survey

Registration Survey

To register, complete the survey below and submit your answers by clicking the SUBMIT button at the end. Before the next course begins, you will be emailed directions to access the course.

You must complete this form with a correct email address to receive your enrollment key and course access directions.

Welcome to Food Safety for Family Daycare Providers. Before we begin, we would like to get some information about you so that we can continue to develop courses such as this in the future. Please take a few minutes to answer all of the questions. Thank you!

All your responses are confidential. However, we would like to keep track of the data to evaluate the effectiveness of this course, so please complete the following information. This information will NOT be shared with or seen by anyone other than members of the course development team.

Important: Please enter your name, address, and email here so we may send you the enrollment key to access the course pages and other materials. A valid email address is needed.

Part 1

Name:
Address:
Town/Zip code:
Telephone:
Fax:
Email:

Please check the most appropriate response.

1. How did you hear about this mini-course? Please check all that apply.
Word of mouth
Website
Listserv
Journal or magazine
Other – please specify

Part 2. About You.

2. Your age range:

21 and under

22-39

40-64

65 and up

3. Your gender:

male

female

4. Your race/ethnicity:

Black/African-American	Asian
Latino/Hispanic	Other:
White

5. Please estimate your family income per year:

less than $10,000	$35,000 to $50,000
$10,000 to $20,000	more than $50,000
$20,000 to $35,000	prefer not to respond

6. I have completed grades in school, including high school, years in college.

Part 3 . Please provide the following information about your day care program.

7. Number of years (approximately) as a child care provider:

8. Number of meals served each week ; Snacks served each week

9. On average, number of children in your care each week