Addressing Substance Use Disorders Among Families Involved with the Child Welfare System: A Cross-Agency Collaboration

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OMB control Number 0990-0421

Expiration Date: October 12, 2020

_Parent Demographic Form

Site ID: _ _ _ _ _

Please provide some information about yourself by completing this questionnaire. We will not report any of your responses by name. Thank you.

BACKGROUND
In what county do you currently live?	____________________________________________
Do you currently describe yourself as male, female or transgender	Male Female Transgender None of these
Would you describe yourself as Hispanic or Latino?	Yes No
How would you describe your racial background? Select all that apply.	American Indian or Alaska Native Asian Black or African American	Native Hawaiian or Other Pacific Islander White
What is your current marital status?	Single Married Living with someone	Separated Divorced Widowed
How many children under the age of 18 do you have?	1 2 3	4 5 6 or more
How many of these children live with you full time	1 2 3	4 5 6 or more
What is the highest education level completed? Select one.	11th grade or less 12th grade but no high school diploma High school diploma or GED Some college or technical school	Associate’s degree Bachelor’s degree Master’s degree Doctoral degree Professional degree (MD, JD, etc.)
What is your current employment status	Full-time employment for wages Part-time employment for wages Self-employed for wages Presently not employed outside the home, looking for work	Presently not employed outside the home, not looking for work Disabled/unable to work Refused/unknown
What is your total household income?	$0 - $3,000 $3,001 - $16,500 $16,501 - $24,000 $24,001 - $34,500	$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

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