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With schools throughout New Jersey back in session, many working parents are still struggling with caregiving responsibilities, The below child care survey can be customized to help determine which employees have responsibilities related to COVID-19 that may interfere with work.  Customize it as you see fit.

Please consider sharing this child care survey with anyone you feel may benefit from it.

It seems clear at this point that we will be dealing with COVID-19 through the remainder of 2020 and most likely into 2021.

Marzano Human Resources Consulting can help your business deal withumber of Covid-19 related issues.   Call for a no-cost consultation.

Please contact us for a Word version of the below survey.


Date:                       ____________________________

Employee name:   ____________________________

Job title:                 ____________________________

Department:          ____________________________


  1. Do you have caregiving responsibilities for a child or other family member due to the COVID-19 pandemic?   Yes/No

    If no, stop here. If yes, please continue the survey.
  2. Where are you currently working:
    ___ On-site
    ___ Telecommuting
    ___ Both
    ___ Other (explain):
  3. Do your caregiving responsibilities interfere with your ability to perform your job?    Yes/No

    If no, please stop here.

    If yes, what days and/or hours are you unableto perform your job?
Mon Tues Wed Thurs Fri Sat Sun


  1. What types of accommodations would allow you to balance your work with your caregiving responsibilities?


[Optional text if you would like to offer examples/suggestions for accommodations:]

Examples include:

  • Working from home.
  • Flexible work hours or workdays.
  • Alternating on-site workdays/weeks to allow caregiving coordination with other family members.
  • Reduced hours.
  • Job sharing.
  • Leave of absence. 
  • Assistance finding childcare or eldercare resources. 
  1. How long do you anticipate these circumstances will last?  Begin date: ______________   End date: __________________

Please provide any additional comments regarding conflicts you may have with work and caregiving responsibilities during the pandemic:


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