Перевод опросника

Необходимо перевести следующую форму, сохранив полностью стилистику.

Refugee Family Support (RFS) Intake         

For Office Use Only: 

Family meets the following criteria: ☐Pregnant or child under 6  ☐ Lives in Sacramento County ☐Arrived in the U.S. after 8/1/2021

__________________________________________________________________________________________________________________This program is funded by First 5 Sacramento, which works with Applied Survey Research (ASR) to evaluate programs and the impact they have on children and families. The information you provide on intake forms and surveys will help us understand how these services are working for you and your family that came to the United States, and to better coordinate care across funded programs. Your personal information is protected by state and federal law and is kept confidential. Please initial here if you agree to participate in this evaluation. Initial: ____________

1. Full Name: __________________________________    2. Date of arrival to United States:  ___________________

3. Date of birth: _____/_____/________ (month/day/year)     4. Country of Origin: _______________________________

5. Primary Phone: (_______) _________- _____________       6. Email Address: _____________________________________

7. Zip Code: ______________                     8. Gender:  🗆 Male  🗆 Female 🗆 Prefer not to answer

9.  Race/Ethnicity: (Select all that apply)                10. Language most comfortable with: (Select only one)

11a. How many people in your immediate family? ____ b. How many are pregnant? ____ c. 0-2 yrs old? _____ d. 3-5 yrs old____

Because your well-being is important to us, we would like to take a few moments to see how you are doing and learn which connections may be most beneficial for you.