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Moms and Moms to be
1.
What is your first and last name?
2.
What is your phone number?
3.
What is your email address?
4.
What is your age?
5.
What city and state are you located?
6.
What is your zip code?
7.
What is your gender?
8.
Are you currently pregnant?
9.
Are you a mom of a child 5yrs old or younger? If so, how old is your child?
10.
What is your race/ethnicity?
11.
Please select the category that best represents your living situation
Live in parent/guardian's home
Live in dorm/group home
Live with spouse/significant other
Live with children/other family members
12.
In your household, who is responsible for making choices regarding the food you and your household eats?
I am primarily responsible
I share the responsibility
Someone else is primarily responsible
13.
How many people in total (including yourself) live in your household?
14.
What is your approximate annual household income for 2022, before taxes, from all sources?
15.
How familiar are you with each of the following programs
Very Familiar
Somewhat familiar
Not to familiar
Never heard of
SNAP or the Supplemental Nutritional Assistance Program
Very Familiar
Somewhat familiar
Not to familiar
Never heard of
WIC or the Special supplemental Nutrition Program for Women, infants, and children?
Very Familiar
Somewhat familiar
Not to familiar
Never heard of
TANF or Temporary assistance for needy families
Very Familiar
Somewhat familiar
Not to familiar
Never heard of
Medicaid
Very Familiar
Somewhat familiar
Not to familiar
Never heard of
CHIP or the Children's health insurance program
Very Familiar
Somewhat familiar
Not to familiar
Never heard of
None of the above
Very Familiar
Somewhat familiar
Not to familiar
Never heard of
16.
Do you currently participate in any of the following programs? Check all that apply
SNAP
WIC
TANF
Medicaid
CHIP
None of the above
17.
For each statement, please tell me whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with that statement
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
Don't know/not sure
I am confident in my ability to make nutritious eating choices
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
Don't know/not sure
I know where to find/purchase nutritious eating choices
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
Don't know/not sure
I eat whatever I want, whenever I want
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
Don't know/not sure
I wish in knew more about healthy eating
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree
Don't know/not sure
18.
In what type of community do you live?
Urban, which is inside a city
Suburban, which is just outside of a city
Small town or Rural, which is father outside of a city, like in the country
19.
Are you available this Thursday May 11 for an online (via Zoom) focus group? As long as you have a webcam on your computer, laptop, tablet, phone with good internet connection, you should be fine. This group could possibly last up to 2hours and compensation is $75. Are you available and interested?