Instrument 3 - Waitlist Survey_11.22.22

OMB #: 0970-0531

Expiration Date: 9/30/2025

Waitlist Survey

Thank you for taking the time to complete this survey. The purpose of this information collection is to help the federal program team understand diaper need in communities across the country. This is a voluntary collection of information. It should take you about 5 minutes to complete this survey. Your responses will be kept private. The information collected will be shared with both federal program staff and a research team, but your responses will be anonymous. Thank you for taking the time to complete this short survey.

1. How many children in diapers do you have?

2. Diaper size per child (1-5)

3. How many times in the past 6 months did you do one or more of the following to stretch diaper supply:

   1. Borrow money or diapers from a family member or friend

   2. Obtain diapers from an agency

   3. Stretch the diaper supply you had by changing less frequently

   4. Kept your child diaperless

4. In an average day, how many diapers do you go through per child?

   1. Less than 3 per day

   2. 3 to 5

   3. 6 to 7

   4. 8 to 9

   5. More than 9

5. What is your most stressful part of your current diaper need? Please select all that apply.

   1. The health and safety of my child(ren)

   2. I am missing days at work

   3. I can’t bring my child(ren) to childcare

   4. I don’t have enough money to buy diapers

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to help the federal program team understand diaper need in communities across the country. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0531and the expiration date is 09/30/2025. If you have any comments on this collection of information, please contact Thom Campbell at [email protected].