Arizona Family Survey Question Title * 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 Question Title * 2. Gender: How do you identify? Male Female Non-binary Prefer not to say Prefer to self-describe: Question Title * 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) Question Title * 4. What is the primary language used in your home? Please fill in the blank. Question Title * 5. Which of the following best describes your current relationship status? Married or partnered Single Other (please specify) Question Title * 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) Question Title * 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 Question Title * 8. Are there services and/or assistance that you think you are eligible for but are not receiving? Yes No Next
