Focus Group Response Form

Form Approved OMB No. 0920-XXXX

Exp. Date __xx/xx/20xx_______

Attachment C5: Focus Group Response Form

Please fill out this form if you are a primary caregiver of a child with spina bifida.

1. How old is the child with spina bifida? __________

2. Is the child

 Male
 Female

3. What is your relationship to the child with spina bifida?

 Parent/Guardian

 Other family member; Please specify_________________________

 Other; Please specify_________________________

4. How long have you attended [clinic name]?

 Less than 1 year  11 years - 15 years

 1 year - 5 years  16 years - 20 years

 6 years - 10 years  21 years or longer

Please indicate whether you are interested in participating in the discussion group:

Name: ___________________________________

 I am available to participate in the discussion group scheduled for: [Day, Date, Time]

Please provide the best telephone number to reach you to confirm your participation:

Your telephone number: ( )

 I am interested, but I would like more information. Please contact me at:

Your telephone number: ( )

 I am interested, but the offered day/time does not fit my schedule.

Please mail this form in the enclosed
postage paid envelope to: Darcy Holtgrave

Battelle CPHRE

10420 Old Olive Street Road,

Suite 300

St. Louis, MO 63141-5939

Or fax it to Darcy Holtgrave at: 1-314-993-5163

If you have any questions, please contact Darcy Holtgrave, Battelle Project Coordinator, at 1-800-444-5234, ext. 109, or [email protected].

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)