EP Short Survey
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- Enter
Full Name (optional):
- Enter
Email Address :
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- 1. City State Town or Providence Country
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- 2. Gender: M
F
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- 3. Age:
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- 4. Number of Children:
Ages of Children:
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- 5. Marital Status:
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- 6. Education:
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- 7. I work at
home as a:
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- 8. The hours/week I work are:
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- 9. I've been working at home
since (month/year):
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- 10. Before becoming
an EP, I was:
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- 11. The catalyst
for my becoming an EP
was:
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- 12. Since working
at home, I earn:
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- 13. Regarding
health insurance:
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- I am covered
by my spouse's employer
- I am uninsured
- Other -- Please
name insurance carrier & monthly costs:
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- 14. The following
challenges have been difficult for me (check off all that apply):
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- Meeting deadlines
while handling family emergencies
- Over-volunteering
at my children's schools
- Taking a "maternity
leave" when I'm self-employed
- Locking
horns with a non-supportive spouse
- Scrambling to
find back-up childcare during business travel and/or late night
client meetings
- Taking care of an elderly
parent who has suddenly fallen ill
- Taking care of a child
who has suddenly fallen ill
- None of the
above
- Other:
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- 15. Since working
at home, I have seen an improvement in my child(ren)'s:
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- Academic Performance
- Behavior
- Social Skills
- Cooperation
- Happiness
and Well-Being
- None of the
Above
- Other:
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- 16. Regarding
my working at home, I would describe my spouse as primarily:
- Supportive
- Non-Supportive
- Indifferent
- N/A
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- 17. My spouse:
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- 18. I use outside
childcare, paid or otherwise:
- Yes No
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- 19. I am the
primary caregiver in my family:
- Yes
No
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- 20. Household
Income:
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- 21. Your Income:
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- Thank you for
your time!
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