Focus Group Participant Characteristics Form_Revised 02.28.25

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Public Burden Statement: This collection of information will be used to learn about demographic characteristics of focus group participants. 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. The OMB control number for this information collection is 0915/0906-XXXX and it is valid until XX/XX/202X. This information collection is voluntary. Data will be kept private to the extent allowable by the law. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

Given what you just read about the purpose of this project, please select a response below.
        ◦ I agree to provide my demographic information to help the ADAPT-HV project describe the characteristics of the focus group sample. [go to Q1] 
        ◦ I do not agree to provide my demographic information. I understand that there is no penalty for not answering these questions. [exit form
[FORM A - Program Staff Focus Group Participants]
    1. What age range do you fall into?
        ◦ 18 to 24
        ◦ 25 to 34
        ◦ 35 to 44
        ◦ 45 to 54
        ◦ 55 to 64
        ◦ 65 to 74
        ◦ 75 or older

    2. Are you: 
    • Female
    • Male

    3. What is your race or ethnicity (select all that apply)?
        ◦ American Indian or Alaska Native (e.g., Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit)
        ◦ Asian (e.g., Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese)
        ◦ Black or African American (e.g., African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali)
        ◦ Hispanic or Latino (e.g., Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian)
        ◦ Middle Eastern or North African (e.g., Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli)
        ◦ Native Hawaiian or Other Pacific Islander (e.g., Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese)
        ◦ White (e.g., German, Irish, English, Italian, Polish, French)
        ◦ I prefer not to answer

    4. How long have you worked at your current organization?
    • Less than 1 year
    • 1 to 5 years
    • More than 5 years

    5. What position do you currently hold at your current organization? Select all that apply.
        ◦ Director
        ◦ Manager
        ◦ Supervisor
        ◦ Home visitor or related service provider
        ◦ Support staff
        ◦ Other program staff (please specify): ____________

    6. For how long have you held this position?
    • Less than 1 year
    • 1 to 5 years
    • More than 5 years
[FORM B - Family Focus Group Participants]
    1. What age range do you fall into?
        ◦ 18 to 24
        ◦ 25 to 34
        ◦ 35 to 44
        ◦ 45 to 54
        ◦ 55 to 64
        ◦ 65 to 74
        ◦ 75 or older

    2. Are you: 
    • Female
    • Male

    3. What is your race or ethnicity (select all that apply)?
        ◦ American Indian or Alaska Native (e.g., Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Tribal Government, Tlingit)
        ◦ Asian (e.g., Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese)
        ◦ Black or African American (e.g., African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali)
        ◦ Hispanic or Latino (e.g., Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian)
        ◦ Middle Eastern or North African (e.g., Lebanese, Iranian, Egyptian, Syrian, Moroccan, Israeli)
        ◦ Native Hawaiian or Other Pacific Islander (e.g., Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese)
        ◦ White (e.g., German, Irish, English, Italian, Polish, French)
        ◦ I prefer not to answer

    4. How old is the child with whom you are participating in home visiting services?
        ◦ Newborn (0 to less than 3 months old)
        ◦ Infant (3 months to less than 1 year old)
        ◦ 1 year to less than 2 years old
        ◦ 2 years to less than 4 years old
        ◦ 4 years to 5 years old

    5. For how many children under the age of 18 are you currently considered the primary caregiver? Please include the child with whom you are participating in home visiting services in this count.
_____ [write-in, numeric]