Learning About Learning Questionnaire

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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:											



















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
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4
    9. Babies were born to be breastfed.
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4
    10. Infant formula is just as healthy as breast milk.
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2
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4
Breastfeeding…




    11. Is beneficial to the mother.
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2
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4
    12. Is painful.
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2
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4
    13. Saves money.
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4
    14. Is beneficial to society.
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    15. Is embarrassing.
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    16. Is natural.
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4
    17. Is beneficial to the father. 
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4
Please circle the answer to the questions below that best matches your response.  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. 
Did The Guide help you…
No, Not
At All
Yes, Definitely

1
2
3
4
    18. Learn about the benefits of breastfeeding to the mother?
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2
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4
    19. Learn about the benefits of breastfeeding to the baby?
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4
    20. Learn how to breastfeed your baby? (e.g., holds, getting baby to suckle)
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4
    21. Decide to breastfeed or plan to breastfeed your baby?
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4
    22. Feel confident that you can successfully breastfeed your baby?  
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4
    23. Feel confident in asking for help with breastfeeding?
1
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4
Did The Guide encourage you to….
No
Yes
    24. Breastfed your baby?
No
Yes
    25. Talk to friends or family about breastfeeding?
No
Yes
    26. Talk to your health care provider about breastfeeding?
No
Yes









Please circle the answer to the questions below that best matches your responses to the following statements?  When responding to each item, use a scale from 1 (No, Not At All) to 4 (Yes, Definitely). 
Did The Guide encourage you to…
No, Not At All


Yes, Definitely

1
2
3
4
    27. Think more about your health in general.
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4
    28. Have a greater understanding of the importance of breastfeeding.
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    29. Learn more about breastfeeding.
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    30. Feel more confident in your decision to breastfeed.
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4
    31. Learn where you can get information about breastfeeding.
1
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4
Did The Guide help you feel more confident in your ability to:
Strongly Disagree
Disagree
Agree
Strongly Agree
    32. Ask your health care provider specific questions about breastfeeding.
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4
    33. Find breastfeeding help over the phone.
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    34. Find breastfeeding help on the Internet.
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    35. Correctly position yourself and the baby when breastfeeding.
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    36. Breastfeed your baby.
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    37. Talk to others about the importance of breastfeeding.
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    38. Breastfeed in public.
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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	
    H. Are you Hispanic or Latino?
    • Yes
    • No
I. What is your race? (Check ALL that apply.)

 Black/African American
 White 
 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.