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| Are you employed outside the home? |
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| If applicable, is your spouse/ significant other/ partner employed outside the home? |
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| Why are you raising your grandchildren? |
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| Have the parents ever been involved in your grandchild's life? |
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| Is the lack of parental involvement causing you stress? |
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| How many grandchildren live in your home? |
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| What are the ages of the grandchildren who live in your home? |
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| How long have the grandchildren lived in your home? |
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| Do you believe that their stay with you is: |
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| When your children came to live with you was the event: |
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| Do you have custody of your grandchildren? |
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| Was custody awarded through the court system? |
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| Were you represented by an attorney? |
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| Was a social service agency involved (ie. CPS, foster care)? |
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| Whose children are you raising? |
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| Does your grandchild have medical problems? |
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| Are the medical problems: |
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| Does your grandchild have emotional or behavioral problems? |
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| Are the emotional or behavioral issues: |
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| Does your grandchild have academic or school problems? |
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| Are the academic and/or school issues: |
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| Are your grandchild's medical, emotional or behavioral, academic or school problems causing you stress? |
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| Have you ever contacted KIPDA for community resource information? |
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| How did you make contact with KIPDA? |
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| Did the referral given meet your needs? |
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| Is the KIPDA grandparent program meeting your emotional needs? |
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| Is the KIPDA grandparent program meeting your social needs? |
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