Name
Address
City
			State			Zip
Phone
# Employees	0-24 25-49 50-99 100-499 500+

1. Is the importance of work/family issues part of your company’s mission statement?
Yes No
2. Does your company collaborate with local community organizations and schools on programs related to working families?
Yes No
If Yes, please identify community organizations/schools
If Yes, please identify types/names of programs

3. What family friendly policies or programs does your company provide? (Please check those that apply)
job sharing/flextime/part-time work schedules accrued sick time can be used to care for dependents, including elder care on site child care services (eg. daycare) or subsidies for child care paid maternity leave support groups for family issues flexible "cafeteria" style benefits plan health insurance available for employees and families employee assistance programs scholarships or educational assistrance for employee dependent enhanced child care resource and referral services information about family-friendly policies/programs made available to employees in languages other than English benefits are provided to part-time employees an on-site break area is provided for employees special events for employees are company hosted company encourages opportunities for employees to call home or child care providers company provides opportunities for employees to call home or child care providers company provides time off for employees to attend educational related activities without deducting such time from accrued vacation, sick or personal days company provides time off for employees to take child/elder to well/sick doctor, dentist or other health care provider appointments without deducting such time off from accrued vacation, sick or personal days. company supports employee wellness through counseling, support groups, fitness programs, etc. company provides continuing education opportunities for employees company organizes and promotes a work/family task force needs assessments on work/family issues are conducted annually Other

Name of Person Completing Survey
Title of Person Completing Survey
I would like to be involved in the Statewide network of business and community leaders
Yes No
Please send parent education/family involvement materials
Yes No