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1. What is your first name? (Required.)

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2. What is your last name? (Required.)

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3. What is your Birthdate? (Required.)

Date

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4. What is your phone number?

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5. What is your email address?

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6. What is your address? (Required.)

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7. Are you currently? (Select all that apply) (Required.)

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8. What is your age? (Required.)

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9. What sex were you assigned at birth, on your original birth certificate? (Required.)

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10. Are you of Hispanic, Latino/a, or Spanish origin? (Select all that apply) (Required.)

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11. What is your race? (Select all that apply) (Required.)

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12. Do you speak a language other than English at home? (Required.)

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13. What language do you speak at home? (If not English)

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14. How well do you speak English? (Required.)

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15. What is the highest grade or level of school that you have completed? (Required.)

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16. Are you parenting a child/children less than 18 months old? (Required.)

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17. How many children under 18 months of age are you parenting?

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18. During the past 12 months, did you see a doctor, nurse, or other health care professional for PREVENTIVE medical care, such as a physical or well-visit checkup? A preventive check-up is when you are not sick or injured, such as an annual or sports physical, or well-visit. (Required.)

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19. During the past 12 months, were you EVER covered by ANY kind of health insurance or health coverage plan? (Required.)

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20. What kind of health insurance do you have now? (Required.)

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21. If you have medicaid, what is the name of your plan?

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22. During the past 12 months, what was your yearly total household income before taxes?

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23. How many adults depend on this income?

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24. How many children depend on this income?

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25. Which of these statements best describes the food situation in your household in the past 12 months?

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26. Has your family consistently had adequate housing over the past 12 months?

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27. Do you feel safe where you are living now?

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28. In the past 12 months, has lack of transportation kept you from medical appointments, community resources, meetings, work or from getting things needed for daily living?

Over the last 2 weeks, how often have you been bothered by the following problems?

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29. Over the last 2 weeks, how often have you been bothered by the following problems?

  Not at all Several Days More than half the days Nearly every day Decline to answer
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless

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30. In the past 12 months, how often have you...

  Daily or Almost Daily Weekly Monthly Less than Monthly Never Decline to answer
Used any tobacco product (for example, cigarettes, e-cigarettes, cigars, pipes, or smokeless tobacco)?
For women: Had 3 or more drinks containing alcohol in one day? For men: Had 4 or more drinks containing alcohol in one day?
Used any cannabis product?
Used any illicit drugs including cocaine or crack, heroin, methamphetamine (crystal meth), hallucinogens, ecstasy/MDMA?
Used any prescription medications just for the feeling, more than prescribed, or that were not prescribed for you?

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31. During the past 12 months, has anyone…

  Current or Former Intimate Partner Other Family Member Someone Else No-one Declined to answer
Threatened you or made you feel unsafe in some way?
Made you feel frightened for your safety or your family’s safety because of their anger or threats?
Tried to control your daily activities, for example, control who you could talk to or where you could go?
Pushed, hit, slapped, kicked, choked, or physically hurt you in any other way?
Forced you to take part in touching or any sexual activity when you did not want to?

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32. Do you want more children?

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33. How long do you plan to wait until you/your partner becomes pregnant again?

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34. Are you currently using a condom to prevent sexually transmitted infections?

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35. What kind of birth control are you currently using to keep from getting pregnant before you are ready? If you are currently pregnant/expecting, what method do you plan to use to prevent becoming pregnant again before you are ready?

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36. Have you ever had a live birth? If so how many?

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37. Did you ever have a pregnancy that did not result in a live birth?

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