Family Leave and Lower Income Families: Linkages between Mothers' Return to Work, Leave, and Child Care

Attachment C—Demographics Questionnaire, 12-14-17

OMB Control Number 0990-0421

Expires October 12, 2020

Paid Family Leave Focus Group: Anonymous Demographics Questionnaire

Your “fake name” for today: __________________________________

1. How old are you? _________

2. How many children do you have? _________

3. How old is your youngest child? _________

4. Does your youngest child’s other parent live with you?

☐ Yes ☐ No

5. Are you of Hispanic, Latino, or Spanish origin? (check one)

☐ Yes ☐ No

6. Which category best describes your race/ethnicity? (check all that apply)

☐ American Indian/Alaska Native ☐ White

☐ Asian

☐ Black or African American

☐ Native Hawaiian/Other Pacific Islander

7. Which category best describes your household’s income per year? (check one)

☐ Less than $25,000 ☐ $25,000-$50,000 ☐ $50,000-$75,000 ☐ More than $75,000

8. How long have you been getting or did you get payments from [Paid Family Leave (CA), Family Leave Insurance (NJ); Temporary Caregiver Insurance (RI)]?

☐ Got/plan to get the full benefit ☐ Got/plan to get just part of the benefit ☐ Not sure

9. Did your child’s other parent also receive payments from [Paid Family Leave (CA), Family Leave Insurance (NJ); Temporary Caregiver Insurance (RI)]?

☐ Yes ☐ No, but plans to ☐ No ☐ Not sure

10. What type of work did you do before you had your last child (e.g., retail, childcare provider, food service)? (No need to tell us who your employer was.)

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 15 minutes per response, including the time to review instructions, search existing data resources, and 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.

11. If you work now, what type of work do you do? (Report “same” if your work has not changed.)