OMB No. 0990-0421, expired date 07/31/17
To be completed by Mission staff with moms identified by partner organization as likely to be eligible
Hello. I received your name because you signed up with (contact name at center name) to possibly participate in a focus group about being a new mom, taking time off from work, and getting support during your time off. As the (center) mentioned, the focus group is part of a study sponsored by the federal government and not related in any way to the services you get from (center). Briefly describe the focus group process, including the date, duration, location, compensation, and the fact that participants will be asked to be audio-recorded.
It’s important to us that we get the right mix of moms for our group, like some moms who took time off and some moms who didn’t. I have just a few questions that I need to ask you before the focus group—to see if you’re the right fit. We will not share or report any of your answers. Is it okay if I ask you a few quick questions?
1. How old is your youngest child? Click here to enter text.
Keep going if there is at least one child under one year of age.
2. For your youngest child, did you work during the year before you gave birth?
☐ Yes ☐ No
Keep going if there is some pre-birth work experience.
3. How much did you work?
☐ Full-time ☐ Part-time ☐ Just a little bit
4. Did you receive a pay stub, or was it more informal—like babysitting or house cleaning?
☐ Pay stub ☐ No pay stub ☐ Don’t know
Keep going if there is some eligible pre-birth work experience.
5. After the birth of your youngest child, did you receive Paid Family Leave or short-term Disability Insurance to support you while you were off? Both Paid Family Leave and short-term Disability Insurance come from the state of California, not your employer.
☐ Yes ☐ No ☐ Don’t know
Ask only if low-income status is not already clear from participation in the center’s programs.
6. Is your household income below $85,000 (San Francisco County)/$62,000 (LA County) a year?
☐ Yes ☐ No
If participant is likely eligible: Thank you for taking the time to answer these questions! While it seems that you are eligible for the focus group, we’ll contact you to confirm your participation in the next couple of days. What is the best way to contact you? Click here to enter text.
If participant is not eligible: Thank you, but it looks like this focus group is not the right fit for you given we’re looking for someone who worked in the year before giving birth/has a lower household annual income/has a child younger than age one. We really appreciate you taking the time to answer our questions!
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 10 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
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kira Gunther |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |