Form 0 Demographic Questionnaire

OMB Control Number: 0990-0421

Expiration Date: October 12, 2020

Attachment C: Demographic Questionnaire

PURPOSE: This document will be used to collect basic demographic information on each of the focus group participants. It will be distributed to participants by email before each focus group. Mathematica will enter the data into a database to allow ASPE to understand the characteristics of the focus group participants.

1. Your “fake name” for today (this is the name we will use instead of your real name during the discussion to protect your privacy?): ___________________________________________________________________

2. How old are you? _________ years old

3. What is your gender? __________

4. How many people live in your household (including you)? ____­­­­­­­­­­­­­­­­­­­­__________________________________________

5. How many children aged 18 and younger live in your household? __________________________________________

6. How many children aged 5 and younger live in your household?___________________________________________

7. What is your total household income during the PAST 12 MONTHS? Note: This is total income for your entire household, not just your own personal income.

$1–$4,999

$5,000–$9,999

$10,000–$14,999

$15,000–$19,999

$20,000–$29,999

$30,000–$39,999

$40,000–$49,999

$50,000–$69,999

$70,000 or more

8. What is the highest level of education that you completed?

Grade school or some high school

High school graduate or GED

Some college, technical, or vocational school, or a 2-year degree

4-year college degree or higher

9. Are you Spanish/Hispanic/Latino? Yes, Spanish/Hispanic/Latino No, not Spanish/Hispanic/Latino

10. 

    1. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0421. The time required to complete this information collection is estimated to average 15 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.

9. What is your race? PLEASE CHECK ALL THAT APPLY.

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or other Pacific Islander

Other race

10. In addition to your participation in [FOCAL PROGRAM NAME], have you participated in any of the following programs in the past 3 months? PLEASE CHECK ALL THAT APPLY.

TANF or other general cash assistance

Head Start

SNAP benefits, also known as food stamps

Child protective services/foster care services

WIC

Healthy relationship or parenting classes or services

Other_______________________

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