Demographic Questionnaire

Paid Family Leave Focus Group: Demographic Questionnaire 0990-xxxx

Your “fake name” for today: __________________________________

General

1. How old are you? _________

2. How many children do you have? _________

3. How old is your youngest child? _________

4. Does your youngest child’s other parent live with you? ☐ Yes ☐ No

5. How many people live in your household (including yourself)? ______

6. Are you Hispanic or Latino? ☐ Yes ☐ No

7. Which category best describes your race? (check all that apply)

☐ American Indian/Alaska Native ☐ Native Hawaiian/Other Pacific Islander

☐ Asian ☐ White

☐ Black or African American

8. Additional comments on your race/ethnicity:

9. Which category best describes your household’s income per year?

☐ Less than $25,000 ☐ $25,000-$50,000 ☐ $50,000-$75,000 ☐ $75,000-$100,000 ☐ $100,000-$125,000 ☐ More than $125,000 ☐ Not sure

Employment

10. What type of work did you do before you had your last child?

11. How much did you work? ☐ Full-time ☐ Part-time ☐ Just a little bit

12. Describe your current job situation:

☐ Back to work at the same job/role ☐ Plan to go back to the same job/role

☐ Back to work at a different job/role ☐ Plan to go back to a different job/role

☐ No plans to return to work

13. If you are changing jobs/role, please describe:

Would you describe your job as?	Job Prior to Giving Birth			Current Job (Leave blank if not working)
	No	A little	Yes	No	A little	Yes
Physically demanding	☐	☐	☐	☐	☐	☐
Mentally/intellectually demanding	☐	☐	☐	☐	☐	☐
Stressful/emotionally demanding	☐	☐	☐	☐	☐	☐

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-xxxx . The time required to complete this information collection is estimated to average ___hours/ minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete 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

Use of Leave Benefit Programs 0990-xxxx

If you are back at work, how many weeks of leave have you taken? If you are still on leave, how many weeks do you plan to take?	Number of weeks
State Disability Insurance (SDI) prior to birth
SDI post birth
Paid Family Leave
Additional employer-sponsored leave, such as sick leave or paid time off/vacation
Unpaid leave*
Total number of weeks away from work*

* If you don’t plan to go back to work, mark N/A

16. Did your child’s other parent receive payments from Paid Family Leave?

☐ Yes ☐ No, but plans to ☐ No ☐ Not sure

Health and Health-Related Behaviors

17. What type of health insurance do you have?

☐ None, uninsured  ☐ Public insurance (e.g., Medi-Cal/Medicaid, Medicare, military)

☐ Private insurance (e.g., employer-sponsored, paid by individual)

18. How would you describe your general health prior to getting pregnant?

☐ Excellent ☐ Very good ☐ Good ☐ Fair ☐ Poor

19. How regularly did you attend your prenatal visits?

☐ Always ☐ Almost always ☐ Missed some ☐ Frequently missed ☐ Never

20. How far along were you when you gave birth (in weeks of pregnancy)?

☐ Full term (37 weeks or after) ☐ 32-36 weeks ☐ 28-31 weeks ☐ Before 28 weeks

21. Since your baby was born, have you been able to see a doctor for your own health (including your six-week appointment)?

☐ Yes ☐ No (Why were you unable to go?)

22. Do/did you breastfeed/pump? ☐ Yes ☐ No

23. If yes: How long did you breastfeed/pump for, or if you are still breastfeeding/pumping, how long do you plan to breastfeed/pump? ______

24. How many hours of sleep do you typically get without waking up at night (i.e., # of hours of longest stretch)? ______

25. How many hours of total sleep do you typically get in a 24-hour period (with daytime naps)? ______

26. How many hours do you typically exercise in a week (including informal exercise, such as walking to bus stop, etc.)? _____

27. How often do you eat fruit or vegetables?

☐ Multiple times a day ☐ Around once a day

☐ Every two or three days ☐ Once a week or less

28. Do you smoke? ☐ Yes ☐ No

29. How many days a week do you drink more than one alcoholic drink?

☐ Never ☐ 1-2 days a week ☐ 3-4 days a week ☐ 5 or more days a week