Stipend Monthly Questionnaire
Caregiver Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
1. Financial Stability / Basic Needs; In the past month, to what extent did the monthly stipend help ensure household stability by providing funding for essential needs such as food, utilities, clothing, transportation, housing, etc.?
Not at all
A Little
Somewhat
Mostly
Completely
2. Child Well-Being: In the past month, to what extent did the monthly stipend help you directly support the children in your care?
Not at all
A Little
Somewhat
Mostly
Completely
3. Stress & Caregiver Well-Being: In the past month, to what extent did the stipend reduce stress about money or reduce stress about caring for the children?
Not at all
A Little
Somewhat
Mostly
Completely
4. Use of Funds / Spending Patterns: Which areas did the stipend help you cover this month? (Select all that apply.)
Food or Groceries
Utilities
Rent/mortgage
Childcare
Transportation (car payment, gas, insurance etc.)
Clothing
Medical/health needs
Counseling or mental health needs
After school care
School related expenses (supplies, books, etc…)
Tutoring or academic support for children
Extracurricular activities for children
Emergency Issues
Entertainment
Other (please describe)
5. Program Satisfaction / Feedback: How satisfied are you with the monthly stipend program?
Very satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
6. Open-Ended Feedback / Success Stories Please share any ways the stipend helped your family this month.
Submit
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