Form 2 Screener

OMB#: 0925-New

EXP: XX/XXX

Attachment 4

Children’s Heart Health Promotion Tracker

Burden Disclosure Statement

Public reporting burden for this collection of information is estimated to average 2 minutes per response, including time for reviewing instructions and completing the screener. 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-XXX).

Screening/Demographics Questions

1. Are you the primary caregiver of a child between the ages of 0 and 7?

1. Yes (continue)

2. No (end survey)

2. Do you, your spouse, or any of your children have a heart condition or other heart problems?

1. Yes (end survey)

2. No (continue)

3. What is your race/ethnicity?

1. White (go to Q5)

2. Black or African American (go to Q5)

3. Hispanic or Latino (go to Q4)

4. Asian (go to Q5)

5. Native Hawaiian or Other Pacific Islander (go to Q5)

6. American Indian or Alaska Native (go to Q5)

4. For Hispanic only: What is your primary language?

1. English

2. Spanish

3. Bilingual with English and Spanish

5. What is your household income level?

1. Below $20,000

2. $20,000-$40,000

3. $40,000-$60,000

4. $60,000-$100,000

5. More than $100,000

6. What is your age? OPEN ENDED

7. What are the ages of your children? OPEN ENDED

For this survey, please think about only one child between the ages of 0 and 7 that you are the primary caregiver for.

8. What age is the child you will focus on for this survey? (Select from 0 to 7) OPEN ENDED

9. Is the child a boy or girl?

1. Boy

2. Girl

10. What is your relationship to this child?

1. Mother

2. Father

3. Grandmother

4. Grandfather

5. Aunt

6. Uncle

7. Other

11. What is your employment status?

1. Work outside the home full-time

2. Work outside the home part-time

3. Work as full-time primary caregiver

4. Unemployed

12. Is your household a single-parent or two-parent household?

1. Single parent

2. Two parent

13. What is the highest level of education you completed?

1. Middle school

2. High school/GED

3. Some college

4. College

5. Graduate school

14. What region of the country do you live in?

1. South

2. Southeast

3. Northeast

4. Midwest

5. Southwest

6. Northwest

7. West

8. Other

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