Potential PFL-eligible low-income mothers

OMB No. 0990-0421, expired date 07/31/17

Anonymous Demographics Questionnaire

Please do not write your name on this paper.

1. How old are you? _________

2. How many children do you have? _________

3. What is the age of your youngest child? _________

4. Does your youngest child’s father live with you? (check one)

☐ No ☐ Yes

5. Are you of Hispanic, Latino, or Spanish origin? (check one)

☐ No ☐ Yes

6. Which category best describes your race/ethnicity? (check all that apply)

☐ American Indian/Alaska Native ☐ White

☐ Asian ☐ Some other race

☐ Black or African American ☐ Declined

☐ Native Hawaiian/Other Pacific Islander

7. Which category best describes your household income per year? (check one)

☐ Less than $25,000 ☐ $25,000-$50,000 ☐ $50,000-$75,000 ☐ More than $75,000

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0421. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer