Take Our Adoption Benefits Survey to Apply for the List

Your organization will be recognized as an adoption-friendly employer on our web site. To be considered for our 2011 Best Adoption-Friendly Workplaces List, complete the online survey below by April 1, 2011.

The first two sections are mandatory to be considered for the list. You may want to have your adoption policy handy for reference, as you will not be able to save your entry for later submission. You will get an email confirmation of the data you entered. If you cannot apply online, please complete and return our Microsoft Word form.

SURVEY CONTACT / ORGANIZATION INFORMATION

How did you hear about us?:*
Did your use our toolkit or technical assistance to establish or enhance your adoption benefits policy?:* (Yes, No, Comments)
Company Name:*
Company Headquarters - City:*
Company Heqadquarters - State / Province:*
Company Web Site:*
Company Industry:*
Total Number of Employees:*
Salutation:*
Your First Name:*
Your Last Name:*
Your Title:*
Your Street Address:*
Your Street Address Line 2:
Your City:*
Your State / Province:*
Your Zip / Postal Code:*
Your Phone (xxx) xxx-xxxx:*
Your E-mail:*
ADOPTION BENEFITS
Maximum Financial Assistance or Reimbursement per Adoption; including any additional assistance for special needs adoption:*
If the amount above does include additional assistance for Special Needs Adoption, what amount?:*
Maximum Weeks of Paid Leave for Adoption (Fully or Partially Paid Leave for Adoption, NOT Accrued Vacation, Sick or Personal Time) (In Weeks):*
Maximum Weeks of Unpaid Leave for Adoption Beyond FMLA (In Weeks):*
IMPLEMENTATION
Criteria for Usage:
Eligible When? (Length of Time Employed):
Date Policy Went Into Effect:	Date and timeNow
Average Utilization Rate Annually (Number of Adoptions):
FACTORS INFLUENCING DECISION (choose as many as apply)
	Employee Requests for Adoption Benefits:
	Equity for Adoptive versus Birth Parents:
	Competitive Work/Life Benefits Package:
	Family-Friendly Image:
	Right Thing to Do:
INCLUSION IN BENCHMARKS
The Foundation shares examples of adoption reimbursement and leave to employers establishing policies upon request:	You may include my organization's name in these reports We prefer to remain anonymous
OTHER SUPPORT OF ADOPTION
Please share with us if your organization supports adoptive parents or the cause of adoption in other ways (i.e. employee adoption networks, inclusion of adoption in your EAP, sponsorship of adoption events, etc.):