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Jefferson County Diaper Bank
Diaper Bank Survey
This survey if for those who are interested in being serviced by our diaper bank program, launching soon.
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1.
Would you benefit from diaper assistance?
(Required.)
Yes
No
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2.
Please list your full name
(Required.)
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3.
What is your 5-digit zipcode?
(Required.)
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4.
Which of the following categories best describes your employment status?
(Required.)
Employed, working full-time
Employed, working part-time
Not employed, looking for work
Not employed, NOT looking for work
Retired
Disabled, not able to work
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5.
How has diaper need impacted your life? Select all that apply.
(Required.)
Negative mental health impact
Diaper rash/infection
Decreasing utility usage, or other spending
Missing work, school, or daycare
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6.
How many children in your household are in diapers?
(Required.)
0 - Pregnant
1
2
3
4+
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7.
Select all diaper sizes being worn.
(Required.)
Preemie
Newborn
1
2
3
4
5
6
7
2T-3T Pull-up
3T-4T Pull-up
4T-5T Pull-up
5T-6T Pull-up
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8.
Select all programs your child is currently enrolled in.
(Required.)
Medicaid
WIC
TANF
AIM Women's Center Baby Boutique
Help Me Grow
None of the above
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9.
Please provide your email and phone number to stay up to date on the latest diaper bank information.
(Required.)
Email Address
Phone Number
Current Progress,
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