Karen Hill Scott - Survey - Focus Group Survey

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	Focus Group Survey Thank you for your interest in joining our electronic focus group, focusing on the needs, challenges and desires of concerned moms. Dads are welcome too, and if we generate enough interest, we will establish a group focused on your perspectives and concerns as well. To assemble this group, we need to ask you to fill out the following form so that we can ensure that all viewpoints and perspectives are included. This information will be kept confidential and will not be personally identifiable. We will ask you to choose a user name and enter your email address so that we can stay in contact with you. If you have any questions or concerns, please email us at info@karenhillscott.com with a subject line of "focus group survey." Thank you! Karen Hill-Scott, Ed.D. By filling out this survey I agree to the terms of the Privacy Policy. Please answer all of the following questions below, to the best of your ability. What is your Email Address: Please enter the month and date of your birth so we can create a unique user name for you in this process: Month: Day: Please choose your parenting role: Mother Father How many children do you have under the age of 16? 1 2 3 4 5 6 or more Please enter the age(s) of your child(ren)? (If you have more than six children, please indicate the ages of the six youngest) years months years months years months years months years months years months How would you classify your work life? (choose the one that best applies) Stay-at-home parent, not employed for pay Work-for-pay-at-home, part-time (PT) Work-for-pay-at-home, full-time (FT) Work-outside-the-home, PT Work-outside-the-home, FT Please indicate your age group? 18-26 27-35 36-44 45+ What is your zip code? How would you describe your community? Urban Suburban Rural How would you describe your racial or ethnic identity? (If you identify with more than one group, check all that apply) Caucasian African-American/Black Hispanic/Latino East Asian Southeast Asian South Asian Middle Eastern Pacific Islander Native American Other Comment: How would you describe your children's racial or ethnic identities? (again, if your children identify with more than one group, check all that apply) Caucasian African-American/Black Hispanic/Latino East Asian Southeast Asian South Asian Middle Eastern Pacific Islander Native American Other Comment: What is your highest level of educational attainment? Up to High School graduate or equivalent Some College Bachelor's Degree Master's Degree or Higher What is your yearly household income range? Less than $35,000 $35,000-$74,999 $75,000-$149,999 Over $150,000 Does your family have a religious or spiritual tradition? (if you are a mixed-faith household, please check all that apply) Protestant Catholic Non-Denominational Christian Jewish Buddhist Hindu Muslim Spiritual Other No Religious Preference Comment: How often does your family attend spiritual or religious services? Weekly Once or twice a month A few times a year Rarely Never How would you describe your home living arrangement? Never Married Unmarried, Living with Partner Married Separated Divorced Widowed If you had one issue, pertaining to your children, that you would like to see addressed by our work, what would it be? If you had one issue, pertaining to your most significant adult relationship, that you would like to see addressed by our work, what would it be?