Form C.9.3 Instruments

Appendix C C.9.3–2

OMB #: 0925-xxxx

Expiration Date: xx/xxxx

NATIONAL CHILDREN’S STUDY

Healthcare Provider Questionnaire (Draft)

Thank you for your interest in the National Children’s Study (NCS). Please take a moment to answer a few questions about your experience with the study. Your feedback will help us improve the National Children’s Study for future phases of the study. Please answer these questions to the best of your ability.

1. How familiar are you with the National Children’s Study?

• Very familiar

• Somewhat familiar

• Not too familiar

• I have not heard of the National Children’s Study

2. In your opinion, how valuable do you think the National Children’s Study will be to the health and well-being of children?

• Not at all valuable

• A little valuable

• Pretty valuable

• Very valuable

3. Have you taken steps to encourage any of your patients to enroll in the Study?

• Yes

• No

4. How much of a burden is it for you when a patient of yours enrolls in the National Children’s Study?

• Very burdensome

• Somewhat burdensome

• A little burdensome

• Not at all burdensome

Thank you for taking the time to complete this questionnaire.

Please put your completed questionnaire in the envelope provided and return the questionnaire to the study representative. If you prefer, you can also return your completed questionnaire by using the postage paid envelope.

Public reporting burden for this collection of information is estimated to average 3 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.