3 Family-Caregiver Demographic Questionanaire

Attachment B3:

Family/Caregiver Focus Group Discussion (FGD)

Background/Demographic Questions

Health Resources and Services Administration Maternal and Child Health Bureau Pediatric Mental Health Care Access Program National Impact Study

April 2024

Family/Caregiver FGD Background/Demographic Questions

JBS International, Inc., HRSA MCHB PMHCA Program National Impact Study (Impact Study) staff will ask identified family members/caregivers the following questions over the phone during their initial contact. These data will be used to inform FGD sampling and data analyses.

Program Information (completed by Impact Study staff prior to reaching out to the identified family member/caregiver):

• Program Name: ­­____________________________________________

• Care Coordinator (or Designee) Name: __________________________________

• Care Coordinator (or Designee) Contact Information:

• Phone: ___________________________________________

• Email: ___________________________________________

Background/Demographic Information:

1. What is your first and last name? _______________________________

2. Is [insert telephone number received from program] your preferred contact number?

   1. Yes

   2. No. If not, what is your preferred contact number? ______________________

3. Is [insert email address received from program] your preferred email address?

   1. Yes

   2. No. If not, what is your preferred email address? ______________________

4. If you are selected to participate in a focus group discussion, would you prefer we call or email you with scheduling information?

   1. Call

   2. Email

5. What is your ZIP code? _______________________________________

6. Is English your preferred language?

   1. Yes

   2. No. If no, what is your preferred language? ___________________________

7. How old is your child/adolescent you have sought and/or received behavioral health care for? If more than one, please specify the ages of each child/adolescent.

   1. Child 1:__________________________________________

   2. Child 2:__________________________________________

   3. Child 3:__________________________________________

   4. Child 4:__________________________________________

   5. Child 5:__________________________________________

8. What is your child/adolescent’s race/ethnicity? (Select all that apply.) *If more than one child/adolescent is identified, this question will be asked for each.

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African American

   4. Hispanic or Latino

   5. Middle Eastern or North African

   6. Native Hawaiian or Pacific Islander

   7. White

   8. Prefer not to disclose

9. What gender does your child/adolescent identify as? *If more than one child/adolescent is identified, this question will be asked for each.

   1. Male

   2. Female

   3. Transgender

   4. Nonbinary/nonconforming

   5. Other, please specify:________________________________

   6. Prefer not to disclose