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FEEDBACK QUESTIONNAIRE FOR INTERNATIONAL ADOPTION PROGRAM

DEAR ADOPTIVE PARENTS,
WE WOULD LIKE TO ASK YOU TO KINDLY AND VOLUNTARILY FILL OUT THIS QUESTIONNAIRE, AS FEEDBACK OF YOUR PARTICIPATION IN OUR ADOPTION PROGRAM. YOUR RESPONSES WILL BE EXTREMELY HELPFUL FOR US IN THE FUTURE AND WILL BE USED TO BETTER UNDERSTAND PARENTS’ AND CHILDREN’S NEEDS DURING THE ADOPTION PROCESS AND IN THE POST PLACEMENT PHASE. ALSO, IF IT IS POSSIBLE FOR YOU TO ATTACH ONE OR MORE RECENT PICTURES OF YOUR ADOPTED CHILD/REN AND ONE OF YOUR WHOLE FAMILY, WE WOULD BE VERY HAPPY TO RECEIVE THEM. WE ARE ALWAYS INTERESTED IN THE PROGRESS OF YOUR FAMILY AND ALSO APPRECIATE BEING ABLE TO SHARE INFORMATION AND PHOTOS WITH STAFF ABROAD WHO HAVE BEEN INVOLVED IN YOUR CASE.
YOUR COOPERATION IS GREATLY APPRECIATED.

MR. DR.	FIRST NAME: LAST NAME:
DR. MS. MRS./MS.	FIRST NAME: LAST NAME:
	STREET ADDRESS:
	TOWN/CITY: STATE: ZIP:
	COUNTRY:
	HOME PHONE: E-MAIL ADDRESS:
	CHILDREN NAME(S): CHILD'S DATE OF BIRTH:
	APPROXIMATE HOUSEHOLD ANNUAL INCOME (OPTIONAL):
	PLACE OF BIRTH AND ADOPTION/AGE OF ADOPTION:

HOW DID YOU HEAR ABOUT OUR ADOPTION PROGRAM?	ADOPTIVE PARENTS OFFICIAL, GOVERNMENT SOURCE AGENCY ADVERTISEMENT MEETING FOR PROSPECTIVE ADOPTIVE PARENTS FRIEND OR RELATIVES' REFERENCE CHURCH OTHER
HOW WOULD YOU DESCRIBE THE HOME STUDY PROCESS?	NO PROBLEM AT ALL SOME DIFFICULTIES IN UNDERSTANDING OTHER, IF APPLICABLE
HOW YOU CAN EVALUATE SERVICES PERFORMED BY YOUR SOCIAL WORKER DURING YOUR HOME STUDY PROCESS?	EXCELLENT GOOD, WITH SOME INSIGNIFICANT DIFFICULTIES POOR, NEED MUCH IMPROVEMENT OTHER
HOW WOULD YOU DESCRIBE HOME STUDY AGENCY FACILITATION DURING YOUR ADOPTION PROCESS?	EXCELLENT GOOD, WITH SOME INSIGNIFICANT DIFFICULTIES POOR, NEED MUCH IMPROVEMENT OTHER
HOW WOULD YOU DESCRIBE THE INTERNATIONAL PROGRAM COORDINATION?	EXCELLENT GOOD, WITH SOME INSIGNIFICANT DIFFICULTIES POOR, NEED MUCH IMPROVEMENT OTHERS, PLEASE SPECIFY
HOW WOULD YOU DESCRIBE THE FACILITATORS ASSISTANCE IN KIEV, MOSCOW OR OTHER CAPITALS?	EXCELLENT GOOD, WITH SOME INSIGNIFICANT DIFFICULTIES NEEDS LANGUAGE IMPROVEMENT, ONLY POOR, NEED MUCH IMPROVEMENT OTHERS, PLEASE SPECIFY
HOW WOULD YOU DESCRIBE FACILITATOR(S) ASSISTANCE IN THE CITY WHERE YOUR ADOPTED YOUR CHILD/REN?	EXCELLENT GOOD, WITH SOME INSIGNIFICANT DIFFICULTIES NEEDS LANGUAGE IMPROVEMENT, ONLY POOR, NEED MUCH IMPROVEMENT OTHERS, PLEASE SPECIFY
HOW WOULD YOU DESCRIBE TRANSPORTATION SERVICES IN RUSSIA, INCLUDING TRAIN, TAXI ETC.?	EXCELLENT GOOD, BUT WITH SOME DIFFICULTIES POOR, INCONVENIENT EXPENSIVE INEXPENSIVE OTHER, PLEASE SPECIFY/ OR INCLUDE YOUR SUGGESTIONS TO THE FACILITATOR OF THE PROGRAM
HOW WOULD YOU DESCRIBE THE CONDITIONS OF ACCOMMODATION IN KIEV, MOSCOW OR OTHER CAPITALS?	EXCELLENT GOOD, BUT WITH SOME DIFFICULTIES POOR, INCONVENIENT EXPENSIVE INEXPENSIVE OTHER, PLEASE SPECIFY/ OR INCLUDE YOUR SUGGESTIONS TO THE FACILITATOR OF THE PROGRAM
HOW WOULD YOU DESCRIBE THE CONDITIONS IN THE CITY WHERE YOU ADOPTED YOUR CHILD?	EXCELLENT GOOD, BUT WITH SOME DIFFICULTIES POOR, INCONVENIENT EXPENSIVE INEXPENSIVE OTHER, PLEASE SPECIFY/ OR INCLUDE YOUR SUGGESTIONS TO THE FACILITATOR OF THE PROGRAM
OVERALL, WHAT DO YOU THINK ABOUT THE ADOPTION PROGRAM?	EXCELLENT, PROFESSIONALLY ORGANIZED GOOD, BUT NEEDS SOME IMPROVEMENT POOR, NEED SERIOUS IMPROVEMENT PLEASE SPECIFY WITH PARTICULAR COMMENTS
CIC SPENDS APPROXIMATELY $ 2,000.00 - 2,500.00 FOR CHARITABLE DONATIONS PER ADOPTION CASE FROM TOTAL AMOUNT OF FEES, WHICH ARE PAID TO FUND THE INTERNATIONAL PROGRAM. DO YOU FEEL THAT THIS IS ENOUGH OR SHOULD THE AMOUNT BE INCREASED FOR BETTER PROVISION TO CHILDREN'S CARE INSTITUTIONS?	NORMAL NEED INCREASE OTHER
OVERALL, WHAT DO YOU THINK ABOUT THE AMOUNT WHICH YOU WERE CHARGED FOR HOMESTUDY, CONSULTING, COORDINATING, SOCIAL WORK AND ADMINISTRATIVE SERVICES IN THE INTERNATIONAL PROGRAM?	LOCAL FEES CONSISTENT WITH OTHER COMPARABLE PROGRAMS EXPENSIVE NORMAL LESS THAN OTHER COMPARABLE PROGRAMS FOREIGN FEES CONSISTENT WITH OTHER COMPARABLE PROGRAMS EXPENSIVE NORMAL LESS THAN OTHER COMPARABLE PROGRAMS
WERE THE MEDICAL EVALUATION RESULTS AT THE TIME OF YOUR CHILD/ -REN'S ACCEPTANCE APPROPRIATE AND CORRECT?	YES NO, PLEASE SPECIFY BELOW
PERIODICALLY CIC ORGANIZES EVENTS OR EFFORTS TO RAISE ADDITIONAL DONATIONS TO THE CHILDREN'S CARE INSTITUTIONS OVERSEAS. WOULD YOU CONSIDER BEING INVOLVED IN SUCH AN EVENT?	NO YES, I WOULD BE INTERESTED IN SUPPORTING AN EVENT IF YES, MOST LIKELY WHAT YOU ARE GOING TO DONATE(PLEASE CHECK ALL APPLICABLE) CHILDREN'S CARE PROVISIONS CHILDREN'S CLOTHES MONEY (YOUR DONATION IS ENTIRELY TAX DEDUCTIBLE)
PERIODICALLY WE WILL PUBLISH BROCHURES AND COMPILE ALBUMS AND INFORMATION ON OUR WEB SITE ABOUT OUR ADOPTION PROGRAM. IN THESE WE WILL PUBLISH SOME PHOTOS OF ADOPTED CHILDREN, ADOPTIVE PARENTS, SHORT STORIES ETC. WOULD YOU LIKE TO BE INCLUDED IN THESE RESOURCES?	NO YES YES, BUT WITH SOME RESTRICTIONS. YOU CAN USE (PLEASE CHECK ALL APPLICABLE): CHILD/-REN PHOTOS FAMILY PHOTOS BOTH OF ABOVE NAMES ABOUT CHILD/-REN OR PARENTS SHORT STORY OF ADOPTION AND CHILD GROWING EXPERIENCE
WHY DID YOU CHOOSE THE ADOPTION PROGRAM YOU CHOSE? PLEASE BRIEFLY DESCRIBE
CAN WE PROVIDE YOUR NAMES , PHONE NUMBER OR E-MAIL TO OTHER ADOPTIVE PARENTS TO SHARE YOUR ADOPTION EXPERIENCE?	YES NO

If you would be so kind,
please attach recent photos of your children and the family, and write a few sentences below about your adoption experience or please attach a reference letter on a separate sheet.
Thank you!

THANK YOU FOR SUBMITTING OUR QUESTIONNAIRE!

PLEASE SEND THIS QUESTIONNAIRE, PICTURES AND REFERENCES (IF APPLICABLE) IN ATTACHED ENVELOPE TO:
ATTN: PROCESSING CENTER. CHILDREN’S INTERNATIONAL. . P.O. BOX 1478, BOSTON, MASSACHUSETTS 02446-0012.
THE ACTUAL FORM COULD ALSO BE DOWNLADED AND PRINTED FROM ATTACHED ACROBAT/ PDF. FILE

YOU CAN ALSO SUBMIT THIS QUESTIONNAIRE ELECTRONICALLY AT WWW.CICADOPT.ORG/FEEDBACK.HTML AND SUBMIT YOUR PICTURES BY E-MAIL IN JPEG OR GIF FORMAT.

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