Parent Survey Telephone Conversation Record
Child Care Provider’s/Center’s Name:
Parent ‘s/Guardian’s Name: ________________________________________________________
Relationship to Child: _____________________________________________________________
My name is ___________. I represent_____________________________. Your child care
provider, (name here)_____________/center (name of center here)______________participates in,
and receives reimbursement from the Child and Adult Care Food Program (CACFP) for the meals
served to your child(ren). In order to ensure the integrity of the program we occasionally conduct
surveys with the parents to verify their child’s(ren’s) attendance in the child care provider’s
home/center. Participation in this survey will assist us in maintaining the integrity of the CACFP.
Following are a few questions to verify your child’s(ren’s) participation in the CACFP. If you
decide not to participate in this survey, benefits to your child(ren) will continue.
Are you aware that your child care provider/center participates in the U.S. Department of
Agriculture Child Nutrition Program?
2. Did you fill out and sign an enrollment form for your child(ren) to enroll on the
CACFP with the child care provider/center noted above?
Do you pay (private pay or DES Child Care Subsidy, with or without co-payment, for your
child(ren)’s care at the child care provider/center noted above?
Is/are the child(ren) still in care at the child care provider’s home/center noted above?
If yes, how many days in the month of__________________________ was/were your
child(ren) in attendance?______________________________________________________
If no longer in care , last day in care._____________________________________________
Name(s) and age(s) of child(ren) in care.__________________________________________
Is/are child(ren) related to child care provider? (Family Day Care Home only)
If yes, what is the relationship?_________________________________________________
10. What is the normal school schedule for the child(ren)?______________________________
11. Was/were your child(ren) in attendance during the month(s) of :______________________?
12. Were there any days your child(ren) was/were not in care due to illness, vacation,
appointments, etc. during the month(s) of :_______________________________________?
13. If yes, describe. _____________________________________________________________
14. ____Is/are your child(ren) in care on weekends?
_____Was/were your child(ren) in care during weekends for the month(s) of
15. ____Is/are your child(ren) in care on holidays?
____Was/were your child(ren) in care during the holiday(s) of: