Diaper Distribution Demonstration and Research Pilot Baseline Data Collection

Beneficiary Enrollment Survey

Welcome!

[Consent Language with Unique ID] 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. This is a voluntary collection of information. It should take you about 5 minutes to complete this survey. Your responses will be kept private. The information collected will be shared with your service provider, 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.

[Consent Language without Unique ID] 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. This is a voluntary collection of information. It should take you about 5 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 your responses will be anonymous.

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 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 0970-0531 and 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.

[For sites using the DDDRP ID] DDDRP participant number

Please enter your participant number. This number will be given to you by your Diaper Distribution Pilot service provider. If you don’t already have it, please ask a staff member.

____________________________

[All cohorts answer; cohorts 1 and 2 respond in caregiver information section rather than this section]

1. Which of the following best describes your interaction with this organization?

   1. This is my first-time receiving diapers

   2. I have been receiving diapers for 1-6 months

   3. I have been receiving diapers for 7-12 months

   4. I have been receiving diapers for more than one year

   5. [option available to cohorts 1 and 2]

Prefer not to share

2. [cohort 3] How many children in diapers do you have?

[All surveys]

Child [1/2/3/4] - Demographic Information

Instructions: Please answer the questions below to the best of your ability. If you don't know the answer to a question or you don't feel comfortable answering, please select "Prefer not to share" and move to the next question. This first section will ask about your child in diapers. If you have more than one child in diapers, please pick one to answer about first. Subsequent pages will ask about your other child(ren).

1. Information for Child 1. Child’s Age

   1. [Cohort 2 without unique ID, cohort 3]

      1. Not yet born

      2. Under 1 month

      3. 1 month

      4. 2 months

      5. 3 months

      6. 4 months

      7. 5 months

      8. 6 months

      9. 7 months

      10. 8 months

      11. 9 months

      12. 10 months

      13. 11 months

      14. 12 months

      15. 15 months (1 and 14/ year old)

      16. 18 months (1 and ½ year old)

      17. 21 months (1 and ¾ years old)

      18. 24 months (2 years old)

      19. 3 years

      20. 4 years

      21. 5 years

      22. 6 years

      23. 7years

      24. 8-11 years

      25. 12-14 years

      26. 15+

      27. Prefer not to share

   2. [Cohort 1 and cohort 2 using unique ID] Please include both months and years, even if one of them is zero:

      1. Months_________

      2. Years____________

      3. Prefer not to share? Please specify________

   3. 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

2. Child’s Ethnicity

   1. Is the child Hispanic, Latino/a, or Spanish origin

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

f. Prefer not to share

2. Your relationship to the child

   1. Parent

   2. Caregiver

   3. Family member

   4. Legal guardian

   5. Prefer not to share

   6. Other (please specify)

1. Diaper size

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

   1. Yes

   2. No

   3. Prefer not to share

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

   1. Yes

   2. No

3. Prefer not to share

6. Does your child in diapers attend childcare?

   1. Yes [if yes, advance to question vii]

   2. No [if no, advance to Caregiver Information Section]

   3. Prefer not to share [if selected, advance to Caregiver Information Section]

7. Do you have to provide diapers to the childcare provider for your child while they are in care?

   1. Yes

   2. No

   3. Prefer not to share

[All surveys] [Next page]

2. Do you have [2/3/4] children in diapers?

   1. Yes [if yes, advance to child 2/3/4 demographic information]

   2. No [if no, advance to caregiver information]

   3. Prefer not to share [if prefer not to share, advance to caregiver information]

[All surveys]

Caregiver Information

Instructions: Please answer the questions below to the best of your ability. If you don't know the answer to a question or you don't feel comfortable answering, please select "Prefer not to share" and move to the next question.

3. How do you describe yourself?

   1. Female

   2. Male

   3. Other (please specify)

   4. Prefer not to share

4. 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

5. Are you Hispanic, Latino/a, or Spanish origin

   1. No, not of Hispanic, Latino/a, or Spanish origin

   2. Yes, Mexican, Mexican American, Chicano/a

   3. Yes, Puerto Rican

   4. Yes, Cuban

   5. Yes, Another Hispanic, Latino/a or Spanish origin

6. 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 (please specify)

   14. Prefer not to share

7. 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

   9. Prefer not to share

8. About how much income does your household typically have in a year’s time?

   1. $0-$14,999

   2. $15,000-$34,999

   3. $35,000-$49,999

   4. $50,000-$74,999

   5. $75,000-$99,999

   6. $100,000 or more

   7. Prefer not to share

9. What is your employment status?

   1. Full employment (40+ hours/week)

   2. Partial employment (<40 hours/week)

   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. Do you have more than one job

    1. Yes

    2. No

    3. Prefer not to share

11. Would you consider yourself a single parent?

    1. Yes

    2. No

    3. Prefer not to share

[All surveys]

Diaper Needs Assessment

Instructions: Please answer the questions below to the best of your ability. If you don't know the answer to a question or you don't feel comfortable answering, please select "Prefer not to share" and move to the next question.

This section will ask you questions about your diaper need in the months before you started receiving diapers from this federal diaper distribution program. Do not worry if you can't remember exact amounts. You can estimate to the best of your ability.

1. How many times in the past [1 month {cohorts 1 and 2}/6 months {for cohort 3}]:

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

      1. 0 times

      2. 1 - 3 times

      3. 4 - 6 times

      4. More than 6 times

      5. Prefer not to share

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

      1. 0 times

      2. 1 - 3 times

      3. 4 - 6 times

      4. More than 6 times

      5. Prefer not to share

   3. Other (please specify)

2. How many times in the past [1 month {cohorts 1 and 2}/6 months {for cohort 3}]:

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

      1. 0 times

      2. 1 - 5 times

      3. 6 - 10 times

      4. 11 - 15 times

      5. 16 - 20 times

      6. 21 times or more

      7. Prefer not to share

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

      1. 0 times

      2. 1 - 5 times

      3. 6 - 10 times

      4. 11 - 15 times

      5. 16 - 20 times

      6. 21 times or more

      7. Prefer not to share

   3. Other (please specify)

3. How many times in the past [1 month {cohorts 1 and 2}/6 months {for cohort 3}] 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

      1. 0 times

      2. 1 - 5 times

      3. 6 - 10 times

      4. 11 - 15 times

      5. 16 - 20 times

      6. 21 or more times

      7. Prefer not to share

   2. Obtain diapers from an organization in your community

      1. 0 times

      2. 1 - 5 times

      3. 6 - 10 times

      4. 11 - 15 times

      5. 16 - 20 times

      6. 21 or more times

      7. Prefer not to share

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

      1. 0 times

      2. 1 - 5 times

      3. 6 - 10 times

      4. 11 - 15 times

      5. 16 - 20 times

      6. 21 or more times

      7. Prefer not to share

   4. Kept your child diaperless

      1. 0 times

      2. 1 - 5 times

      3. 6 - 10 times

      4. 11 - 15 times

      5. 16 - 20 times

      6. 21 or more times

      7. Prefer not to share

   5. Other (please specify)

4. 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

      1. Strongly disagree

      2. Disagree

      3. Neutral

      4. Agree

      5. Strongly agree

      6. Prefer not to share

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

      1. Strongly disagree

      2. Disagree

      3. Neutral

      4. Agree

      5. Strongly agree

      6. Prefer not to share

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

      1. Strongly disagree

      2. Disagree

      3. Neutral

      4. Agree

      5. Strongly agree

      6. Prefer not to share

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

      1. Strongly disagree

      2. Disagree

      3. Neutral

      4. Agree

      5. Strongly agree

      6. Prefer not to share

   5. Other (please specify)