Exit this survey Survey of Families with Diaper Need Question Title * 1. Please provide your contact information: Name: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: Question Title * 2. Are you now or have you ever had to choose between buying diapers and any of the following: Food Utility Bills Child Care No, I've never been forced to choose between diapers and food, utilities or child care. Question Title * 3. Have you ever had to re-use a dirty disposable diaper because you couldn't afford to buy enough diapers? Yes No Question Title * 4. Have you considered using cloth diapers to cut down on your diapering expenses? Yes No Question Title * 5. Do you have access to a washer / dryer? Yes No Question Title * 6. Are you currently in school and/or working? Yes, I'm in school. Yes, I'm working. None of the above. Question Title * 7. If you had easier access to diapers, would you be in school and/or working? Yes, I'd be in school Yes, I'd be working Yes, I'd be working and in school No Question Title * 8. Are you currently using childcare? Yes, I pay for childcare entirely on my own. Yes, I am using subsidized childcare. No, I don't use childcare. Question Title * 9. Are you currently using any of the following programs: WIC (Women, Infants & Children) SNAP (Supplemental Nutrition Assistance Program - "food stamps") TANF (Temporary Aid to Needy Families) CCDF (Child Care and Development Block Grant - "subsidized child care") NONE OF THE ABOVE Other (please specify) Question Title * 10. How are you currently paying for diapers? I don't have trouble buying diapers. I'm using things around the house to diaper my baby. I'm paying for diapers by not paying for other things. Friends and family are providing my diapers. My church provides my diapers. I get diapers from a diaper bank. I'm using TANF funds to buy diapers. I'd rather not say. Other (please specify) Question Title * 11. Why is your family experiencing diaper need? Question Title * 12. How many children do you have? What are their ages? Question Title * 13. Why would access to diapers (cloth or disposable) help you? Question Title * 14. Is there anything else we should know about your story? Question Title * 15. We would like to use your story (without disclosing your full name or address) to provide public exposure to the issue of diaper need. May we have permission to share your story and photo with appropriate members of Congress, the press, and to the public through http://www.jenniferlabit.com? Yes No Question Title * 16. We'd like to have a photo of you and your children to attach to your story. Please email your photo to jenn@cottonbabies.com with the subject "Diaper Need: <your name>". Did you email the photo? Yes No Done