Demographic Questionnaire 
Moms Study 


       Mom's First Name                                                   Last Name (first initial)             

​       Baby's First Name                                                   Baby's Date of Birth

RACE/ETHNICITY

1a. What is your race or ethnicity? 

​1b. Are you of Hispanic, Latino, or Spanish origin?

AGE

2.   How old are you?

EDUCATION

3. What is your level of education? 

​4. Do you know your mother's level of education?

​MARITAL STATUS/PARENTAL STATUS/LIVING ARRANGEMENTS

5a. What is your marital status?                                                 5b. How many biological children do you have?

​6. What are your living arrangements?

​7a. How many people live in the household?                                           7b. Of those, how many are children?

EMPLOYMENT

​8a. Are you currently:                                                        8b. Are you the sole breadwinner in the household?
​   
(If not employed skip to #10)

​9a. What best describes the work you do? 

​9b. # hours per week you USUALLY work at your job?                                                             9d. Pay status?

​9e. If hourly, do you make minimum wage?                                               9f. Do you work more than one job?

​10. Do you consider your household income enough to meet your and your family’s needs?


11a. What state do you currently live in?                                   11b. Is the area you live in considered to be:  


​                                    Click the button to submit this form, and you 
                                   will then be taken to the next set of questions.