THE LEADING DIAGNOSTIC AND EDUCATION CENTER FOR CHILDREN WITH HEARING LOSS Demographic Form Step 1 of 4 - Child Information 0% All identifying information will remain confidentialJohn Tracy Center’s funders require that we report on the demographics of the families in our services each year. This report dictates how much funding we receive.Child's Gender (Assigned at Birth):(Required) Female Male Family history of hearing loss?(Required) Yes No If yes, family member’s relationship(Required) Mother Father Sibling Family member None Unknown Did your child pass his/her newborn hearing screening (NBHS)?(Required) Yes No Child’s Race:(Required) American Indian/Alaska Native Asian Black/African American Caucasian Filipino Hispanic/Latino Native Hawaiian/Pacific Islander Two or more races Child(ren) lives with:(Required) Both parent Parent 1 Parent 2 Guardian(s) Total # of people living in the home: (circle total)(Required)123456781010+Residence Type:(Required) Rent Home Rent Apartment Own Home Live with Family or friends Currently Unhoused Parent/Guardian 1 Work Status:(Required) Part-Time Full-Time Full time + Part time Unemployed Parent/Guardian 1 Education Level:(Required) <8th grade Some high school High school diploma / GED Some college Degree Post graduate degree Parent/Guardian 2 Work Status:(Required) Part-Time Full-Time Full time + Part time Unemployed Parent/Guardian 2 Education Level:(Required) <8th grade Some high school High school diploma / GED Some college Degree Post graduate degree Annual Family Income:(Required) Less than $25,000 $25,000-49,999 $50,000-74,999 $75,000-99,999 $100,000-124,999 $125,000-149,999 $150,000-199,999 $200,000 or more How Were You Referred to John Tracy Center?(Required) Pediatrician Teacher/School Friend Audiologist Speech Pathologist Former/Current JTC Family JTC’s Worldwide Parent Education Courses Other {all_fields}CAPTCHAInstagramThis field is for validation purposes and should be left unchanged.
