Easy Guide to Breastfeeding Survey

Form Approved

OMB No. 0990-XXXX

Exp. 07-XX-2008

Easy Guide to Breastfeeding – Feedback Survey

Thank you for taking the time to complete this Participant Feedback Survey for the Easy Guide To Breastfeeding (The Guide). Please keep in mind that all survey responses are anonymous. Your honest responses will help the Office on Women’s Health improve their current materials and create new materials for women.

Please answer the following questions about the Easy Guide To Breastfeeding:

1. How did you receive a copy of the Guide?

 Community health fair  Internet  Doctor  Nurse

 Professional conference or event  Class/Workshop  Lactation Consultant

 Peer Counselor  National Women’s Health Information Center

 Other (please specify):­­_____________ __________________________________

2. How much of the Guide did you read?

 Little or none  Less than half  More than half  Almost all or all

3. How much did you like the Guide?

 Not at all  Not very much  Somewhat  Very much

4. How attractive was the format or design of the Guide (i.e. color, pictures, font)?

 Not at all attractive  Not very attractive  Somewhat attractive  Very attractive

5. How useful was the Guide?

 Not at all useful  Not very useful  Somewhat useful  Very useful

6. How does the Guide compare to other health information materials you have read?

 Not as good  About the same  Better than most

 I have not received any other breastfeeding information

7. Would you recommend the Guide to a friend or family member?

 No, definitely not  No, probably not  Yes, probably  Yes, definitely

8. I chose to read the Guide because (check all that apply):

 I had specific questions about breastfeeding

 I had problems or complications with breastfeeding

 I wanted to learn more about breastfeeding in general

 A health care provider recommended it

 A friend or family member recommended it

 Other:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average ( hours)(minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/ocio/PRA, 200 Independence Ave., S.W., Suite 531-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer. Alice Bettencourt

Please circle the answers to the questions below that best match how much you agree or disagree with the following statements? When responding to each item, use a scale from 1 (No, not at all) to 4 (Yes, definitely).
	No, Not at all			Yes, Definitely
	1	2		3			4
Babies were born to be breastfed.	1	2		3			4
Infant formula is just as healthy as breast milk.	1	2		3			4
Breastfeeding…
Is beneficial to the mother.	1	2		3			4
Is painful.	1	2		3			4
Saves money.	1	2		3			4
Is beneficial to society.	1	2		3			4
Is embarrassing.	1	2		3			4
Is natural.	1	2		3			4
Is beneficial to the father.	1	2		3			4
Please circle the answer to the questions below that best matches what you knew or felt AS A RESULT OF reading the Guide. When responding to each item, use a scale from 1 (No, not at all) to 4 (Yes, definitely) or respond with a no or yes.
AS A RESULT OF reading the Guide?			No, Not At All			Yes, Definitely
			1		2	3		4
Do you know about the benefits of breastfeeding to the mother?			1		2	3		4
Do you know about the benefits of breastfeeding to the baby?			1		2	3		4
Do you know how to breastfeed your baby? (e.g., holds, getting baby to suckle)			1		2	3		4
Are you breastfeeding or planning to breastfeed your baby?			1		2	3		4
Do you feel confident that you can successfully breastfeed your baby?			1		2	3		4
Do you feel confident in asking for help with breastfeeding?			1		2	3		4
			No			Yes
Have you breastfed your baby?			No			Yes
Have you talked to friends or family about breastfeeding?			No			Yes
Have you talked to your health care provider about breastfeeding?			No			Yes

Please circle the answer to the questions below that best matches how much you agree or disagree with the following statements? When responding to each item, use a scale from 1 (Strongly Disagree) to 4 (Strongly Agree).
AS A RESULT OF reading the Guide…	Strongly Disagree	Disagree	Agree	Strongly Agree
I have thought more about my health in general.	1	2	3	4
I have a greater understanding of the importance of breastfeeding.	1	2	3	4
I plan to learn more about breastfeeding.	1	2	3	4
I feel more confident in my decision to breastfeed.	1	2	3	4
I know where I can get information about breastfeeding.	1	2	3	4
AS A RESULT OF reading the Guide, I feel more confident in my ability to:	Strongly Disagree	Disagree	Agree	Strongly Agree
Ask my health care provider specific questions about breastfeeding.	1	2	3	4
Find breastfeeding help over the phone.	1	2	3	4
Find breastfeeding help on the Internet.	1	2	3	4
Correctly position myself and the baby when breastfeeding.	1	2	3	4
Breastfeed my baby.	1	2	3	4
Talk to others about the importance of breastfeeding.	1	2	3	4
Breastfeed in public.	1	2	3	4

Additional Comments

39. Please provide additional comments about the Easy Breastfeeding Guide below.

Please answer the following questions about yourself.
A. How often do you get a physical examination from a health care provider?
 More than once each year  Once a year  Every 2-3 years		 Every 4-5 years  I do not regularly visit a doctor
B. How often do you get a pap smear? [A pap smear is a test given by a gynecologist or obstetrician to screen for cervical cancer]
 Once a year  Every 2-3 years		 Every 4-5 years  I do not regularly get a pap smear
C. How often do you perform a breast self-examination?
 Once a month or more  A few times a year		 Once a year or less  I do not perform breast self-examinations
D. Please describe your marital status (check ALL that apply):
 Single  In a relationship  Married		 Separated or divorced  Widowed  Other (please specify):
E. Please check ALL of the following that apply:
 I have never been pregnant  I plan to get pregnant within the next six months  I am currently pregnant		 I am the mother of a baby younger than 1 yr. old  I am the mother of a child older than 1 yr. old  None of the above
F. How many children do you have?
 0  1	 2  3	 4  5 or more
G. How old are you?  Under 18 yrs  25-29 yrs  40-49 yrs  60-69 yrs  18–24 yrs  30-39 yrs  50-59 yrs  70+ yrs
I. What is your race? (Check ALL that apply.)  Black/African American  White/Caucasian  Hispanic or Latino  American Indian or Alaska Native  Native Hawaiian or other Pacific Islander  Asian			J. What is the highest level of education that you have completed?  Part of high school  High school graduate / GED  Part of college / university  College / university graduate  Graduate school
K. For how much of this past year have you had health insurance? I have had health insurance for the entire year. I have had health insurance for part of the year. I did NOT have any health insurance during the past year.
M. In what city and state do you live? ___________________________ _________ City State
N. Are you?  Female  Male
O. Are you a health care provider or health educator?  No  Yes

Thank you for taking the time to complete this survey.

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