Diaper Distribution Demonstration and Research Pilot Baseline Data Collection

ID#:________

Beneficiary Enrollment Survey

Thank you for taking the time to complete this survey. The purpose of this information collection is to help the federal program team understand diaper need in communities across the country. By completing this survey a second time, you are providing valuable information to help assess changes in diaper need in your community over time. This is a voluntary collection of information. It should take you about 15 minutes to complete this survey. Your responses will be kept private. The information collected will be shared with both federal program staff and a research team, but no personal identifying information will be shared. Thank you for taking the time to complete this short survey.

Demographic Information

1. What organization is providing you with diapers?

2. Which of the following best describes your interaction with [partner organization]?

   1. This is my first-time receiving diapers from [partner organization]

   2. I have been receiving diapers from [partner organization] for 1-6 months

   3. I have been receiving diapers from [partner organization] for 7-12 months

   4. I have been receiving diapers from [partner organization] for more than one year

   5. Prefer not to share

3. Household information

   1. How many children in diapers do you have?

2. Information for Child 1. Please complete for each child in diapers.

   1. Child’s Age

   2. Child’s Race (select one or more)

      1. American Indian or Alaska Native

      2. Asian

      3. Black or African American

      4. Native Hawaiian or Other Pacific Islander

      5. White

      6. Select one or more

      7. Prefer not to share

   3. Child’s Ethnicity

      1. Is the child Hispanic, Latino/a, or Spanish origin (Select one or more)

a. ____No, not of Hispanic, Latino/a, or Spanish origin

b. ____Yes, Mexican, Mexican American, Chicano/a

c. ____Yes, Puerto Rican

d. ____Yes, Cuban

e. ____Yes, Another Hispanic, Latino/a or Spanish origin

4. Your relationship to the child

5. Does your child have any special needs that have been diagnosed by a professional?

   1. Yes

   2. No

6. Is this child enrolled in Early Head Start or Head Start?

   1. Yes

   2. No

3. Do your children in diapers attend childcare?

   1. Yes

   2. No

   3. If yes, do you have to provide diapers to the childcare provider for your child(ren)while they are in care?

      1. Yes

      2. No

4. How do you describe yourself?

   1. Female

   2. Male

   3. Other

   4. Prefer not to share

5. What is your race? (Select one or more)

   1. Black or African American

   2. American Indian or Alaska Native

   3. Asian

   4. Native Hawaiian or Other Pacific Islander

   5. White

   6. Prefer not to share

6. Are you Hispanic, Latino/a, or Spanish origin (Select one or more)

a. ____No, not of Hispanic, Latino/a, or Spanish origin

b. ____Yes, Mexican, Mexican American, Chicano/a

c. ____Yes, Puerto Rican

d. ____Yes, Cuban

e. ____Yes, Another Hispanic, Latino/a or Spanish origin

7. What is your primary language?

   1. English

   2. Spanish

   3. Chinese (Cantonese, Mandarin)

   4. Tagalog

   5. Vietnamese

   6. French and/or French Creole

   7. Arabic

   8. Korean

   9. Russian

   10. German

   11. Bilingual

   12. Multilingual

   13. Other

   14. Prefer not to share

8. Would you consider yourself a single parent?

   1. Yes

   2. No

   3. Prefer not to share

9. What is your employment status? Please select all that apply (i.e., student and partial employment)

   1. Full employment (40+ hours/week)

      1. Do you hold more than one job?

         1. Yes

         2. No

   2. Partial employment (<40 hours/week)

      1. Do you hold more than one job?

         1. Yes

         2. No

   3. Student enrolled in school and/or training program

   4. Unemployed and seeking employment

   5. Unemployed due to disability and unable to seek employment

   6. Unemployed and not seeking employment due to another reason. Please explain:

10. What is the highest level of education you have completed?

    1. Less than 6th grade

    2. Middle school (6th, 7th, 8th)

    3. Some high school

    4. High school (diploma)

    5. Some college

    6. Associate degree (AA or AS)

    7. Bachelor’s degree (BA or BS)

    8. Advanced degree

Diaper Needs Assessment

4. How many times in the past 1 month:

   1. Has your child(ren) had a diaper rash, bladder infection, or other diaper-related health issue?

   2. Have you had to take your child(ren) to the emergency department due to a diaper-related health issue?

   3. Did your child(ren) miss childcare or school due to inadequate diaper supply?

   4. Did you miss work due to inadequate diaper supply?

5. How many times in the past 1 month did you do one or more of the following to stretch your diaper supply:

   1. Borrow money or diapers from a family member or friend

   2. Obtain diapers from an organization in your community

   3. Stretch the diaper supply you had by changing less frequently

   4. Kept your child diaperless

6. On a scale of 1-5 (with 1 being strongly disagree and 5 being strongly agree), please rate your agreement with the following statements:

   1. I typically have enough diapers to change my child as often as I need to

   2. I often must reduce spending on other essential needs (food, utilities, etc.) to afford diapers

   3. I often feel stress about having enough diapers for my child(ren)

   4. I often feel stress about being able to provide my family with essential needs such as food, clothes, and shelter

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to help the federal program team understand diaper need in communities across the country. Public reporting burden for this collection of information is estimated to average 15 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 0970-0531and the expiration date is 09/30/2025. If you have any comments on this collection of information, please contact Thom Campbell at thom.campbell@acf.hhs.gov.