Attach. 9 Family Demographic Questionnaire OMB #: 0925-0661
Executive Function Expiration Date: 06/30/2015
Family Demographic Questionnaire
The following questions provide helpful background information about the child participating in this study and your family background. Please answer all questions as best you can. If you choose not to answer a question, let us know by crossing out the question with an X so we know that you meant to skip that one.
Today’s date:
_ _ _ _ _ _ _ _
Month Day Year
Age of parent/guardian completing this form:
_____ years
Parent/Guardian is __ Female __ Male
Participating child’s date of birth
_ _ _ _ _ _ _ _
Month Day Year
5. Participating child is: __ Female __ Male
6. What is your relationship to the participating child? Select one.
Biological mother Biological father
Stepmother Stepfather
Adoptive mother Adoptive father
Foster mother Foster father
Grandmother Grandfather
Aunt Uncle
Romantic partner of parent
Older sister or brother
Other
8. Was the participating child born before 37 weeks gestation (more than 3 weeks early)?
No
Yes
9. Are you currently living with a partner?
No
Yes…GO TO Question 9a
9a. Length of relationship:
Less than 6 months
6 months to a year
1 to 3 years
3 to 6 years
6 to 10 years
10+ years
10. What is your current marital status?
Married
Separated
Divorced
Widowed
Never married
11. Are you of Hispanic, Latino/a, or Spanish origin? (One or more categories may be selected.)
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, Another Hispanic, Latino/a, or Spanish origin
12. What is your race? (One or more categories may be selected.)
White
Black or African American
American Indian or Alaska native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
13. Is the participating child of Hispanic, Latino/a, or Spanish origin? (One or more categories may be selected.)
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, Another Hispanic, Latino/a, or Spanish origin
14. What is participating child’s race? (One or more categories may be selected.)
White
Black or African American
American Indian or Alaska native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
15. What is the primary language spoken in your home? Select one.
English
Hmong
Somali
Spanish
Other _________________________
16. What other languages are spoken at home?
English
Hmong
Somali
Spanish
Other _________________________
16. Does the participating child currently attend any of the following at this time? Check all that apply.
1st grade
Kindergarten
Preschool, Head Start, early education program
Center daycare or afterschool program
Home daycare or afterschool program
Does not attend any daycare or education program outside the home
17. Has the participating child ever attended an early childhood program, preschool, or Head Start?
No
Yes
Elementary school
Middle school/junior high school
Some high school but no degree
Some high school with GED
High school graduate (HS diploma)
Some college
Associates/Vo-Tech Degree
Graduated college (bachelor’s degree)
Some Graduate/Professional School
Post-graduate Degree (M.A., Ph.D., MD
19. Are you currently employed? This includes temporary work and self-employment.
No … Go To Questions 20 and 21
Yes… Go To Question 22
20. How long has it been since you last held a job?
Less than 6 months
6 months to a year
1 - 2 years
2 - 3 years
3 – 5 years
5 or more years
Never employed
21. Are you currently looking for work?
No
Yes
22. What are your main sources of financial income at this time? Check all that apply.
My own job
Government funds
Romantic partner/spouse
Parents
Other family members
Friends
Other
23. What was your total household income last year, in [2012, 2013]?
(before taxes, not including food stamps)
Less than $5000
$5000 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000 - $124,999
$125,000-$149,999
$150,000-$174,999
$175,000-$199,999
Over $200,000
Don‘t know
Prefer not to answer
24. How long have you lived in this state?
Less than 2 months
Less than 1 year
1-2 years
3-5 years
6-10 years
11-20
Over 20 years
25. Where do you currently live?
Home that I own
Home that I rent
Shelter or transitional housing
Sharing a place with family or friends
Other______________
26. Are you or another parent/guardian of the participating child currently serving in the military (Army, Navy, Marines, Air Force, National Guard or Reserves)?
No
Yes
Don’t know
27. At how many different addresses has the participating child lived during his/her life?
1
2
3
4
5 or more
28. How many times (including now) has the participating child ever been homeless?
0
1
2
3
4
5 or more times
Public
reporting burden for this collection of information is estimated to
average 7 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the
collection of information. An agency may not conduct or sponsor, and
a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this
burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC
7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0661). Do not return
the completed form to this address.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Parent Survey |
| Author | Janette |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |