Client Demographic Data Survey Please tell us about the person in need of diapers or briefs Date* MM slash DD slash YYYY Zip Code* ZIP Code Name of Partner Agency*Arizona Baptist Children’s ServiceA-Mountain Church of God in ChristAmphitheater Parents as TeachersArizona Youth Partnership – Starting Out Right- PimaArizona Youth Partnership – Starting Out Right- GilaArmory Park Senior CenterAVIVA Children's ServicesB’nai B’rith Covenant HouseBenson Hospital – TMC HealthcareBhutanese Mutual Assistance Assoc.Casa De Los NiñosCatholic Community ServicesChild and Family ResourcesChildren's ClinicsChrist Church United Methodist Food BankCommunity Action Human Resources Agency (CAHRA)El Rio Community Health CenterEMERGE! Center Against Domestic AbuseFriendship Missionary Baptist ChurchGrace Temple Missionary Baptist ChurchGreater Vail Community ResourcesHands of HopeIMPACT of Southern ArizonaInternational Rescue Committee (IRC)JobPathLas Artes Arts & Education CenterLutheran Social Services/Refugee FocusMarana Resource CenterMobile Meals of TucsonMorris Air National GuardMUSD Family Resource CenterNew Life Pregnancy CenterOur Family Services/ Homeless Youth ServicesPascua Yaqui Charitable OrganizationPima Council On AgingPima County Health DepartmentPrimavera FoundationSt. Luke's HomeSUSD Teenage Parent ProgramSVdP St Cyril of Alexandria ParishThe Lending ShedTucson Indian CenterTUSD – Teenage Parent High SchoolU of A Cooperative Extension – Santa CruzWhere are you getting Diapers or Briefs from today? Use the drop down arrow to view selections and choose your answer.Is this the first time you have received diapers or briefs this year?*YesNoUse the drop down arrow to view selections and choose your answer.Gender of the Diaper/Brief User*SelectMaleFemaleUse the drop down arrow to view selections and choose your answer.Age of the Diaper/Brief User*Select0-17 years18-59 years60+ yearsUse the drop down arrow to view selections and choose your answer.Race of Diaper/Brief User*SelectAmerican IndianAsianBlackPacific IslanderWhiteAmerican Indian & WhiteAsian & WhiteBlack & WhiteAmerican Indian & BlackOther/Multi-RacialUse the drop down arrow to view selections and choose your answer.Ethnicity of Diaper/Brief User*SelectHispanicNot HispanicUse the drop down arrow to view selections and choose your answer.Head of Household*SelectMaleFemaleUse the drop down arrow to view selections and choose your answer.Does the Diaper/Brief User have a place to live?*SelectYesNoUse the drop down arrow to view selections and choose your answer.Is the Diaper/Brief User disabled?*SelectYesNoUse the drop down arrow to view selections and choose your answer.How many in your household? (Enter numbers only)* Use the drop down arrow to view selections and choose your answer.Annual Income*SelectBelow $10,000$10,000-$20,000$20,000-$30,000$30,000-$40,000$40,000-$50,000Over $50,000Use the drop down arrow to view selections and choose your answer.How many diapers did you receive today?*01020304050Use the drop down arrow to view selections and choose your answer. Don’t forget to click SUBMIT below!!! Thank you!CommentsThis field is for validation purposes and should be left unchanged.
