According
to the Paperwork Reduction Act of 1995, no persons are 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 [60 or 90]
minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete
and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: U.S. Department of Health &
Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite
336-E, Washington D.C. 20201, Attention: PRA Reports Clearance
Officer
OMB
control Number 0990-0421
Expiration
Date: October 12, 2020
BACKGROUND
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In
what county do you currently live?
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____________________________________________
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Do
you currently describe yourself as male, female or transgender
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Transgender
None
of these
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Would
you describe yourself as Hispanic or Latino?
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How
would you describe your racial background? Select all that apply.
|
|
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What
is your current marital status?
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Single
Married
Living
with someone
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Separated
Divorced
Widowed
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What
is the highest education level completed? Select one.
|
|
Associate’s
degree
Bachelor’s
degree
Master’s
degree
Doctoral
degree
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What
is your current employment status
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Full-time
employment for wages
Part-time
employment for wages
Self-employed
for wages
Presently
not employed outside the home, looking for work
|
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What
is your total household income?
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$0
- $3,000
$3,001
- $16,500
$16,501
- $24,000
$24,001
- $34,500
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$34,501
- $49,999
$50,000
- $74,999
$75,000
- $99,999
$100,000
- $124,999
$125,000
and greater
I
prefer not to say
|
Do
you currently receive any public government benefits or benefits
from “state-specific name” (e.g., Medicaid, food
stamps, SSI, or welfare cash assistance)?
|
Child
care subsidies
Child
Tax Credit
Disability
benefits
Earned
Income Tax Credit
Education
and training assistance
Housing
voucher or public housing
Medicaid
Medicare
Military
medical insurance
Retirement
benefits
Social
Security Insurance (SSI)
State
Children’s Health Insurance Program (SCHIP)
State
or local emergency assistance program
Supplemental
Nutrition Assistance Program (SNAP)
Temporary
Assistance to Needy Families (TANF)
Transportation
subsidies
Unemployment
compensation
Veteran’s
benefits
|
For
Focus Groups: CAREGIVING
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We
are interested in learning more about your role as a caregiver and
your relationship to the children for whom you provide care.
Please answer the following questions about the minor children
(under 18 years) you currently care for who live in your home.
|
What
type of caregiver would you say you are? Select all that apply.
|
|
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How
many minor children (under 18 years of age) are you currently
caring for that live in your home full time?
|
|
|
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What
are the ages of these children?
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______________________________________________________________
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How
many of these children are your biological,
adopted,
or step
children?
|
|
|
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For
how many of these children are you a kinship
caregiver
(relative by blood or marriage)?
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|
|
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How
many of the minor children in your care are foster
children?
|
|
|
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Do
you currently receive any public government benefits or benefits
from “state-specific name” (e.g., Medicaid, food
stamps, SSI, or welfare cash assistance) for any of the children
involved in your care?
|
Child
care subsidies
Child
Tax Credit
Earned
Income Tax Credit
Housing
voucher or public housing
Medicaid
Military
medical insurance
Social
Security Insurance (SSI)
State
Children’s Health Insurance Program (SCHIP)
State
or local emergency assistance program
Supplemental
Nutrition Assistance Program (SNAP)
Temporary
Assistance to Needy Families (TANF)
|
If
yes, please indicate the name of the child welfare agency
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______________________________________________________________
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