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Arizona Family Survey
1.
How many children ages birth to three years do you take care of in your household? (Please count the children who are “dependents” on your tax forms.)
0
1
2
3
4 or more
None of the above
2.
Gender: How do you identify?
Male
Female
Non-binary
Prefer not to say
Prefer to self-describe:
3.
What is your racial or ethnic identity? (Select all that apply.)
African-American/Black
East Asian
Hispanic/Latinx
Middle Eastern
American Indian/Alaskan Native
Pacific Islander
South Asian
Southeast Asian
White
Other (please specify)
4.
What is the primary language used in your home? Please fill in the blank.
5.
Which of the following best describes your current relationship status?
Married or partnered
Single
Other (please specify)
6.
Please select the option that best describes your total annual family income before taxes. [Family income includes the total combined annual income of all family members in the household. Family income may also include earned income, child support, and Social Security payments.]
Less than $10,000
Between $10,000 to $14,999
Between $15,000 to $24,999
Between $25,000 to $34,999
Between $35,000 to $49,999
Between $50,000 to $74,999
Between $75,000 to $99,999
Over $100,000
Other (please specify)
7.
Does your family currently receive any of the following types of assistance? Please select all that apply.
AHCCCS - Medicaid
KidsCare
Arizona Early Intervention Program (AzEIP)
Early Head Start and/or Head Start
DES Cash Assistance/TANF
SNAP/Nutrition Assistance
WIC - Special Supplemental Nutrition Program for Women, Infants, and Children
Rental Assistance
None of the above
8.
Are there services and/or assistance that you think you are eligible for but are not receiving?
Yes
No
