Parent focus group demographic questionnaire

TOPIC CATEGORY	QUESTION	RESPONSE CATEGORIES
Instructions	Voluntary, don’t need to answer all Qs, answer for any child between 0 and 3 years old who attend child care
Date	Today's date	MM/DD/YY
Gender	Please indicate whether you are male or female.	MALE/FEMALE
Age	In what year were you born?	4 DIGIT YEAR
Education/ Credentials	What is the highest level of education you have completed?	MARK ONLY ONE 1. 1st up to 8th grade 2. 9th to 11th grade 3. 12th grade but no diploma 4. High school diploma or GED 5. Associate's degree 6. Bachelor's degree 7. At least one year of course work beyond a Bachelor's but not a graduate degree 8. Master's degree 9. Education specialist or professional diploma based on one year of course work past a Master's degree level 10. Doctorate 11. Other (Please specify)
Ethnicity	Are you of Spanish, Hispanic, or Latino origin?	Yes/ No
Race	What is your race?	MARK ALL THAT APPLY 1. White 2. Black or African American 3. American Indian or Alaska Native 4. Asian 5. Native Hawaiian or other Pacific Islander 6. Other Pacific (please specify)
Primary/ first language	What is your first language?	1. English 2. Spanish 3. Other (Specify)
All languages	Please indicate any other languages you speak fluently.	1. English 2. Spanish 3. Other (Specify)
Household income	In the last 12 months, what was the total income of all members of your household from all sources before taxes and other deductions? Please include your own income and the income of everyone living with you. Was it . . .	Less than $15,000 $15,000 to $24,999 $25,000 to $49,999 $50,000 to $74,999 $75,000 to 150,000 $150,000 or more
State	In what US state do you live?	OPEN-ENDED
Relationship of respondent	What is your relationship to the child under 3 years old?	1. Mother/Female Guardian 2. Father/Male Guardian 3. Grandmother 4. Grandfather 5. Other Relative 6. Other Non-Relative
Child care	How many of your children received any type of child care on a weekly basis for at least 8 hours a week between birth and when they were 3 years old?	ONE TO TWO DIGIT RESPONSE
Child care	Please mark the boxes to indicate if any of your children were in child care at these ages.	MARK ALL THAT APPLY 1. Birth to five months 2. 6 to 11 months 3. 1 to 2 years, 2 to 3 years 4. 3 years and older
Current child care	Which of the following types of child care are you currently using for a child 3 years old or younger on a weekly basis?	MARK ALL THAT APPLY 1. Early Head Start 2. A State Child Care program 3. A child care center, preschool or nursery school (other than Early Head Start or a State Child Care program) 4. Someone cares for your child in a home that you and the caregiver share 5. Someone cares for your child in their home 6. Someone cares for your child in your home
Child care	Which of the following types of child care have you ever used on a weekly basis?	MARK ALL THAT APPLY 1. Early Head Start or a State Child Care program 2. A child care center, preschool or nursery school (other than Early Head Start or a State Child Care program) 3 Someone cares for your child in a home that you and the caregiver share 4. Someone cares for your child in their home 5 Someone cares for your child in your home
Special Needs	Have any of your children between the ages of 0 and 3 years old been evaluated by a doctor, psychologist or other health professional because of a concern about his or her development?	Yes/ No
Language with child	What language do you speak most often to your children?	1. English 2. Spanish 3. Other (Specify)