Attach B3. LOI2-QUEX-14 Socio-Demographics Questionnaire OMB #: 0925-0593
Expiration Date: 08/31/2014
Nutrition LOI Socio-demographics Instrument
(Infants and Preschoolers)
Administrative Information
Date: // Staff ID:
Instructions for the staff: Enter the answer given by the participant for each response. Use only a black ball-point pen. Do not use a pencil or felt-tip pen. Circle your answer. If changes need to be made, cross out the incorrect response and circle the correct answer.
Instructions for parent completing the questionnaire: The purpose of this questionnaire is to obtain general information about you and your child. Answer each question as best you can. Making a guess is better than leaving an answer blank. |
How many people, both children and adults, live in your household? Include any persons who usually stay but are temporarily away on business, vacation, in the hospital, on full-time active military duty, or students living temporarily away from home. Do not include anyone who is in a nursing home or other institution. Including yourself, what is the total number of people who live in your household?
|___|___|
NUMBER
Refused 98
Don’t know 99
Now I’d like to ask about your marital status. What is your current marital status? Are you:
Married 01
Not married but living together with a partner
of the other sex 02
Not married but living together with a partner
of the same sex 03
Widowed 04
Divorced 05
Separated 06
Never been married 07
Refused 98
Don’t know 99
Are you 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
What race do you consider yourself to be? You may select one or more (select all that apply).
White 1
Black or African American 2
American Indian or Alaskan Native 3
Asian Indian 4
Chinese 5
Filipino 6
Japanese 7
Korean 8
Vietnamese 9
Other Asian 10
Native Hawaiian 11
Guamanian or Chamorro 12
Samoan 13
Other Pacific Islander 14
Some other race (specify): 15
Refused 9--97
Don’t know 9--98
Does the father of the child consider himself to be Hispanic, Latino 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
What race does the father of the child consider himself to be? You may select one or more (select all that apply).
White 1
Black or African American 2
American Indian or Alaskan Native 3
Asian Indian 4
Chinese 5
Filipino 6
Japanese 7
Korean 8
Vietnamese 9
Other Asian 10
Native Hawaiian 11
Guamanian or Chamorro 12
Samoan 13
Other Pacific Islander 14
Some other race (specify): 15
Refused 9--97
Don’t know 9--98
Please look at the card and tell me what is the highest degree or level of school that you have completed?
No school (skip to question 10) 0
Less than a High School Diploma or GED 1
High School Diploma or GED 2
Some College but no degree 3
Associate Degree 4
Bachelor’s Degree (for example, BA, BS) 5
Post Graduate Degree (for example, Masters OR Doctoral) 6
Refused 9--97
Don’t know….. 9—98
Are you currently a full- or part-time student? This includes vocational or technical schooling that may not be done in a classroom.
No, not a student (skip to question 10) 1
Yes, full-time student 2
Yes, part-time student 3
Refused 8
Don’t know 9
What type or types of school are you currently attending?
High school 1
Technical school 2
College or university 3
Graduate school 4
Professional school (e.g., medical, law, dental) 5
Other (specify): 6
Refused 8
Don’t know 9
Are you currently employed?
Yes 1
No 2
Refused 8
Don’t know 9
Were you born in the United States?
Yes (skip to question 12) 1
No 2
Refused 8
Don’t know 9
In what country were you born?
Specify:_____________________________________________
(Source: http://www.state.gov/s/inr/rls/4250.htm#note2)
Refused 98
Don’t know 99
About how long have you lived in the United States?
|___|___|
YEARS
Refused 98
Don’t know 99
Was your mother born in the United States?
Yes (skip to question 13) 1
No 2
Refused 8
Don’t know 9
In what country was your mother born?
Specify:_____________________________________________
(Source: http://www.state.gov/s/inr/rls/4250.htm#note2)
Refused 98
Don’t know 99
Was your father born in the United States?
Yes (skip to question 14) 1
No 2
Refused 8
Don’t know 9
In what country was your father born?
Specify:_____________________________________________
(Source: http://www.state.gov/s/inr/rls/4250.htm#note2)
Refused 98
Don’t know 99
Please look at the card and tell me of these income groups, which category best represents your household income during the last calendar year?
Less than $4,999 01
$5,000-$9,999 02
$10,000-$19,999 03
$20,000-$29,999 04
$30,000-$39,999 05
$40,000-$49,999 06
$50,000-$74,999 07
$75,000-$99,999 08
$100,000-$199,000 09
$200,000 or more 10
Refused 98
Don’t know 99
Do you currently receive benefits from the WIC program, that is, the Women, Infants and Children program?
Yes 1
No 2
Refused 8
Don’t know 9
Are you or any members of your household authorized to receive SNAP (which includes a food stamp card or voucher, or cash grants from the state for food)?
Yes 1
No 2
Refused 8
Don’t know 9
Does your child currently attend a childcare center or a family childcare home?
Yes 1
No (skip to question 17b) 2
Refused 8
Don’t know 9
If Yes, how many days per week?
|___|___|
Days per week
Refused 98
Don’t know 99
b. If No, who takes care of your child during the week? (circle all that apply)
Mother of the child 1
Father of the child 2
A grandparent of the child 3
Other family member 4
Other 5
Refused 8
Don’t know 9
Does your child currently attend aftercare?
Yes 1
No 2
Refused 8
Don’t know 9
Circle the meal(s) typically served to your child in the childcare facility or school when s/he is away from home? (circle all that apply)
Breakfast 1
Morning snack 2
Lunch 3
Afternoon snack 4
Dinner 5
Don’t know 8
Refused 9
Do you provide the meals or does the childcare facility or school provide the meals?
I provide meals 1
Childcare center/school provide meals 2
Combination – both school/childcare and self 3
This question is about your ethnicity, your ethnic group and how you feel about it or react to it. Choose the answer to indicate how much you agree or disagree with the following statement.
I have a strong sense of belonging to my own ethnic group.
Strongly agree 1
Agree 2
Neither agree nor disagree 3
Disagree 4
Strongly disagree 5
Don’t know 8
Refused 9
Thank you for your time and participation!
Public reporting burden for this collection of information is estimated to average 10 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 (0925-0593). Do not return the completed form to this address.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Nutrition LOI Socio-demographics Instrument |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |