Diaper Distribution Demonstration and Research Pilot Baseline Data Collection

Formative Data Collections for ACF Program Support

Instrument 2 - Beneficiary Survey - Follow-up Version

Diaper Distribution Demonstration and Research Pilot Baseline Data Collection

OMB: 0970-0531

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Beneficiary Enrollment Survey

Welcome!

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. If you are new to the program, this is not the right survey for you. Please tell a staff member this is the wrong link. 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 3 - 4 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.

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 4 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.





























DDDRP participant number section

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.

_________________________

If your service provider can’t find your Diaper ID number, please stop here. Thank you for your time.





  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 baseline]

Prefer not to share

  1. How many children in diapers do you have?



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).



Information for Child [1/2/3/4]

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

        1. Yes

        2. No

3. Prefer not to share

      1. Does your child in diapers attend childcare?

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

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

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





    1. 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]



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.

    1. How do you describe yourself?

      1. Female

      2. Male

      3. Other (please specify)

      4. Prefer not to share



    1. 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



    1. 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



    1. 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





    1. 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



    1. 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



    1. 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:


    1. [Display only for those selecting employment or partial employment to the prior question] Do you have more than one job

      1. Yes

      2. No

      3. Prefer not to share



    1. Would you consider yourself a single parent?

      1. Yes

      2. No

      3. Prefer not to share









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.

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 {cohort 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)



  1. How many times in the past [1 month {cohort 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)





  1. How many times in the past [1 month {cohort 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)



  1. 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



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File Created2024-10-07
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