Training and technical assistance provider focus group demographic questionnaire

TOPIC CATEGORY	QUESTION	RESPONSE CATEGORIES
Instructions	Voluntary, don’t need to answer all Qs, answer for any child between 0 and 3 years old who attend child care
Date	Today's date	MM/DD/YY
Gender	Please indicate whether you are male or female.	MALE/FEMALE
Age	In what year were you born?	4 DIGIT YEAR
Education/ Credentials	What is the highest level of education you have completed?	MARK ONLY ONE 1. 1st up to 8th grade 2. 9th to 11th grade 3. 12th grade but no diploma 4. High school diploma or GED 5. Associate's degree 6. Bachelor's degree 7. At least one year of course work beyond a Bachelor's but not a graduate degree 8. Master's degree 9. Education specialist or professional diploma based on one year of course work past a Master's degree level 10. Doctorate 11. Other (Please specify)
Ethnicity	Are you of Spanish, Hispanic, or Latino origin?	Yes/ No
Race	What is your race?	MARK ALL THAT APPLY 1. White 2. Black or African American 3. American Indian or Alaska Native 4. Asian 5. Native Hawaiian or other Pacific Islander 6. Other Pacific (please specify)
Primary/ first language	What is your first language?	1. English 2. Spanish 3. Other (Specify)
All languages	Please indicate any other languages you speak fluently.	1. English 2. Spanish 3. Other (Specify)
Household income	In the last 12 months, what was the total income of all members of your household from all sources before taxes and other deductions? Please include your own income and the income of everyone living with you. Was it . . .	Less than $15,000 $15,000 to $24,999 $25,000 to $49,999 $50,000 to $74,999 $75,000 to 150,000 $150,000 or more
State	In what US state do you live?	OPEN-ENDED
Job title	What is your job title?	OPEN-ENDED
Institutional affiliation	What institution(s) are you currently affiliated with?	MARK ALL THAT APPLY 1. Cultural and Linguistic Responsiveness 2. Early Head Start National Resource Center 3. National Center on Health 4. Parent, Family, and Community Engagement 5. Program Management and Fiscal Operations 6. Quality Teaching and Learning
Experience with infants and toddlers	How many years have you been working in the field of infant and toddler care?	____ NUMBER OF YEARS