Career Development Questionnaire (Company)

Company Name *

Primary Contact First Name

Primary Contact Last Name

Job Title of Primary Contact

Registry ID # of Primary Contact

Company Email Address

[Physical] Street Address

[Physical] City

[Physical] State

[Physical] Zip Code

[Physical] County

Program Category Type

Certified Family

Licensed Family

Licensed Group

Licensed Exempt Public School

Unregulated

Pre-Licensing Family

Pre-Licensing Group

Public School Program

Company Phone Number

Preferred Contact Method *

Phone

I consider myself

American Indian or Alaska Native

Asian (includes Asian Indian, Japanese, Chinese, Korean, Vietnamese, Filipino or other Asian)

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander (includes Samoan, Chamorro or other Pacific Islander)

White

Two or More Races

Other

Language

English

Spanish

Hmong

Other

Other (Please specify)

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YoungStar Rating

License Number/Facility ID

Enter 7 digits

Provider & Location Number

Enter 10 digits-3 digits

What topics do you want to learn more about in the next year? (Check all that apply)

Child Care Licensing

Child Care Certification

Trainings in my area

Credit for Prior Learning (CPL)

Accreditation

Taking college courses

Financial supports to take college courses

The Registry system

Earning a degree or credential

Teacher licensure from Wisconsin Dept of Public Instruction (DPI)

CDA (Child Development Associate)

Financial rewards for longevity in the field

Other

Select other if interested in meeting with a counselor to discuss a staff presentation.

Other (Please specify)

What is the most important goal you have for your program or staff members?

What is another goal you have for your program or staff memebers?

Are any of the following barriers to your program goals?

I do not have access to high-speed internet

The cost is too high

It will take too long to complete/too much work

I am uncomfortable with the idea of registering for and taking courses at a college/university

I don’t have transportation

I’m concerned about my own family’s needs

I don’t know of any training and/or higher education opportunities close to me

Filling out paperwork/forms

Language Barriers

Not Sure

Other

Other (Please specify)

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