Diaper Dash Portal

The Diaper Dash Portal
Thank you for taking the time to complete this application.

This is a voluntary collection of information, and it should only take you about 15 minutes to complete. This information aims to help understand diaper needs in communities across the State of South Carolina. The collected information will be shared with program staff and a research team, but your responses will be anonymous. Thank you for taking the time to complete this enrollment application.

Please complete this form in its entirety.

Consent for the Release of Information
The South Carolina Association of Community Action Partnerships Incorporated, Distribution Among Service Hubs (D.A.S.H.) Collaborative Project is committed to keeping the information you have provided safe and confidential. The purpose of this document is to inform you that your responses will be kept private. Certain information you have provided herein, will be used to assist the Office of Community Services, Division of Community Discretionary and Demonstration Projects research team, as well as local Community Action Agency programs.

I understand that some of the information I provide to the South Carolina Association of Community Action Partnerships (SCACAP) will be shared with the research team. As a condition of the South Carolina Association of Community Action Partnerships’ (SCACAP) funding, SCACAP is required to share data with the research team and federal staff for research and evaluation purposes. SCACAP will not utilize personal identifying information (such as name, address, or Social Security number) that could identify me, before sharing files with the research team and federal program staff. My personal identity will never be part of any research reports.
1. What is your full name?*
2. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Telephone number*
May we contact you? ( for purposes of the program)*

YesNo
4. Email address (Required)*
example@example.com
5. How did you hear about us? (If you select Local Community Action Agency or Head Start/Early Head Start please specify)*
Local Agency*
Local Agency*
HS/EHS Center*
HS/EHS Center*
Demographic Information
6. Which of the following best describes your interaction with the South Carolina Association of Community Action Partnerships (SCACAP)*

This is my first-time receiving diapers from SCACAP.I have been receiving diapers from SCACAP for 1-6 months.I have been receiving diapers from SCACAP for 7-12 months.I have been receiving diapers from SCACAP for more than one year.I prefer not to share.
Household Information
7. How many children in diapers do you have?*

Please fill out the following:

	CHILD'S AGE	CHILD'S ETHNICITY	CHILD'S GENDER	CHILDS RACE (American Indian, Asian, Black or African American, Native Hawaiian, Other Pacific Islander, White, Other, Prefer not to share) ENTER ALL THAT APPLY BELOW:
Child #1
Child #2 (If necessary)
Child #3 (If necessary)
Child #4 (If necessary)

	Relationship to the child	Diaper Size	Select the box below if your child has any special needs diagnosed by a medical professional.	Select the box below if your children in diapers attend childcare.	Select the box below if your are you required to provide diapers to your childcare provider.
Child #1
Child #2 (If necessary)
Child #3 (If necessary)
Child #4 (If necessary)

	Select the box below if Is this child is enrolled in Early Head Start or Head Start.	Select the box below if this child is on the Early Head Start or Head Start waiting list?	Select the box below if your child is enrolled in First Steps
Child #1
Child #2 (If necessary)
Child #3 (If necessary)
Child #4 (If necessary)

8. How would you describe yourself?*
What are your preferred pronouns? (For example, he/him/his, she/her/hers, them/they/theirs
9. What is your race?

American IndianAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhitePrefer not to shareOther
10. What is your ethnicity?*
11. What is your primary language?*
12. Would you consider yourself a single parent?*
13. What county do you live in?
14. What is your employment status?

Full employment (40+ hours/week)Partial employment (≤40 hours/week)Student enrolled in school and/or training programUnemployed and seeking employmentUnemployed due to disability and unable to seek employmentUnemployed and not seeking employment due to another reason (please explain below)
Do you have more than one job?*

YesNo
15. About how much income does your household typically have in a year’s time?*
16. What is the highest level of education you have completed?*

17. Answer the questions in the table below:

	Has your child(ren) had a diaper rash, bladder infection, or other diaper-related health issue?	Have you had to take your child(ren) to the emergency department due to a diaper-related health issue?	Did your child(ren) miss childcare or school due to inadequate diaper supply?	Did you miss work due to inadequate diaper supply?
How many times in the past 6 months

18. Answer the questions in the table below

	Borrow money or diapers from a family member or friend?	Obtain diapers from an organization in your community?	Stretch the diaper supply you had by changing less frequently?	Kept your child diaper less?
How many times in the past 6 months did you do one or more or the following to stretch your diaper supply?

19. On a scale from 1-5 (with 1 being strongly disagree and 5 being strongly agree), please rate youragreement with the following statements:

1 - Strongly Disagree
2 - Disagree
3 - Neutral
4 - Agree
5 - Strongly Agree
a. I typically have enough diapers to change my child as often as I need to.*
b. I often must reduce spending on other essentials needs (food, utilities, etc.) to afford diapers.*
c. I often feel stress about having enough diapers for my child(ren).*
d. I often feel stressed about being able to provide my family with essential needs such as food, clothes, and shelter.*
20. Do you currently have health insurance coverage?*

YesNo
Select your health insurance below:*

MedicaidMedicareMilitary Health CareEmployer Health CareDIrect Purchase (healthcare.gov)
21. Do your children currently have health insurance coverage?*

YesNo
Select your health insurance below:*

MedicaidMedicareMilitary Health CareEmployer Health CareDIrect Purchase (healthcare.gov)
Housing Information
22. What is your current housing status?*

OwnRentHomelessOther Permanent HousingOther
23. Housing Type*

HouseApartmentDuplexTownhomeMobile HomeOther
24. Household Type*

SingleSingle Parent FemaleSingle Parent MaleSingle Parent OtherTwo Parent HouseholdNon-Related Adults with ChildrenMulti-Generational Household (i.e., grandmother, mother, child)Other
25. Marital Status*

SingleMarriedDivorcedSeparatedWidowed
26. Household Size*

OneTwoThreeFourFiveSix+
Benefits
27. Please select all benefits that you are currently receiving.

SNAPWICTANFFILIHEAPHousing VoucherPublic HousingHUDABC VoucherNONEOther
Media Release
I grant The South Carolina Association of Community Action Partnerships Incorporated, Distribution Among Services Hubs (D.A.S.H.) Collaborative Project the right to use my name, image, and statements, as recorded and/or photographed, for the promotion of The South Carolina Association of Community Action Partnerships Incorporated and its subsidiaries and programs. I hereby release The South Carolina Association of Community Action Partnerships Incorporated, and its subsidiaries and programs from all liability associated with the use of my name, image and statements.
By checking this box, I am agreeing with the terms and conditions mentioned above, and I'm digitally putting my signature on this part of the application.By checking this box, I DECLINE the right to use my name, image and statements for promotion by The South Carolina Association of Community Action Partnerships Incorporated and its subsidiaries and programs
Diaper Distribution
28. Do you give an alternate person permission to receive information about this application?*

YesNo
Alternative Pick-up Name*
List email of alternate person below:*
example@example.com
29. How many children in your household are in diapers or training pants: *

30. Please list the names of your children and the correct size in diapers or training pants:

	Child Name	Diaper Size	Training Pants Size
Child #1
Child #2 (if applicable)
Child #3 (if applicable)
Child #4 (if applicable)
Child #5 (if applicable)

I would like additional information about the following: (Please select all that apply)

Diaper ProgramEarly Head StartHead StartChildcareTransportationWeatherizationUtility AssistanceFamily DevelopmentFood AssistanceTax AssistanceRefugee ServicesSubstance TreatmentHomelessness ProgramsJob TrainingHealth InsuranceParentingGED/High School Diploma CompletionHUD Housing AssistanceMental HealthSmoking CessationContinuing EducationCollege Prep Associates/BachelorsFinancial LiteracyEmploymentRental AssistanceWater AssistanceOther
Upload documentation here:

Cancelof
It is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this application for services. Furthermore, I hereby certify that the provided information is true and accurate to the best of my knowledge and abilities.
Signature

Clear
Date

MonthDayYear
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The Diaper Dash Portal

Consent for the Release of Information

Demographic Information

Household Information

Housing Information

Benefits

Media Release

Diaper Distribution