Instrument 7: Participant Characteristics Form

Instrument 7

Participant Characteristics Form

Understanding and Expanding the Reach of Home Visiting
(HV-REACH) C-intake Case Study

Participant Characteristics Form

You are receiving this form because you completed an interview with the HV-REACH project. This form will take up to five minutes to complete and will help us understand who participated in our interviews. You are not required to complete the form. The information in this form will not be shared with anyone outside of our research team and will not be able to be linked to your name or other information about you. In addition, when we share participant information in our reports, we will report numbers in total so no individual participant will be identifiable. HV REACH has been given Institutional Review Board (IRB) approval by Health Media Lab Institutional Review Board.

PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13) STATEMENT OF PUBLIC BURDEN: 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 0970-0XXX and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Harshini Shah at hshah@mathematica-mpr.com.

Thank you for completing!

For all participants

1. What is your race and/or ethnicity?

Select all that apply

o American Indian or Alaska Native 1

For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native

Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

o Asian 2

For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

o Black or African American 3

For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

o Hispanic or Latino 4

For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

o Middle Eastern or North African 5

For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

o Native Hawaiian or Pacific Islander 6

For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

o White 7

For example, English, German, Irish, Italian, Polish, Scottish, etc.

2. How do you identify your gender?

Select only one

o Female

o Male

o Non-binary

o Prefer not to answer

3. How old are you?

Select only one

o 18-24

o 25-34

o 35-44

o 45-54

o 55-64

o Older than 65

o Prefer not to answer

For families only

1. What language(s) do you and your household members speak at home?

Select all that apply

o English

o Spanish

o French

o Cambodian (Khmer)

o Chinese

o Haitian Creole

o Hmong

o Japanese

o Korean

o Vietnamese

o Arabic

o African language (e.g., Somali, Swahili, Hausa, Yoruba, Laal, Shabo, Afrikaans, Awing, Bargu, Tumbuku, Teso, and Dahalo)

o Native American or Alaskan language

o A Filipino language (e.g., Tagalog)

o Other (specify)

o Prefer not to answer

2. How many children do you have? ______ (optional)

3. What are the ages of your children (optional):

Child 1 ____ years

Child 2 ____ years

Child 3 ____ years

Child 4 ____ years

Child 5 ____ years

Child 6 ____ years

Child 7 ____ years

Child 8 ____ years