Form 3_Revised Family/Caregiver Demographic Questionnaire

OMB No. 0906-0097

Expiration Date: 7/31/2027

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 is your child’s/adolescent’s sex? *If more than one child/adolescent is identified, this question will be asked for each.

   1. Male

   2. Female

Public Burden Statement: The data collected through this information collection request will examine the impact of the Maternal and Child Health Bureau (MCHB) Pediatric Mental Health Care Access (PMHCA) program (the Impact Study). This project will collect data to provide HRSA with information to guide future program decisions regarding the PMHCA program as it relates to (1) the impact of HRSA’s PMHCA program on changes in children/adolescents’ and their families/caregivers’ access to behavioral health care; their subsequent receipt and utilization of behavioral health care services, including culturally and linguistically appropriate care; and related behavior health impacts, and (2) monetary and societal PMHCA program costs and benefits. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0097 and it is valid until 7/31/2027. This information collection is voluntary. Data will be kept private to the extent allowed by law. Public reporting burden for this collection of information is estimated to average approximately 5 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.