1 Survey

Appendix A A.2.1.g–6

Video Enrolled (6/30/2008)

National Children’s Study

Consent Questionnaire

Instructions

Please use a black or blue pen to complete this form.

Mark [X] to indicate your answer.

If you want to change your answer, mark [X] on the wrong answer.

Put your completed questionnaire in the envelope and return it to the interviewer.

 The following questions ask for your opinion on the video you viewed earlier in this visit.

1. In your opinion, how much of the information in the video did you need to know to decide whether to participate in the study?

• None of it

• Some of it

• Most of it

• All of it

2. In your opinion, how much of the information in the video was easy to understand?

• None of it

• Some of it

• Most of it

• All of it

3. Overall, do you think the video provided…

• Too much detail,

• About the right amount of detail, or

• Not enough detail?

4. In general, how interesting did you find the video to watch?

• Not at all interesting

• A little interesting

• Somewhat interesting

• Very interesting

5. Do you think the amount of time it took to watch the video was:

• Far too long,

• A little too long,

• About the right amount of time,

• A little too short, or

• Far too short?

6. In general, how difficult or easy was it to ask questions or get more information about something you saw or heard in the video?

• Very difficult

• Somewhat difficult

• Somewhat easy

• Very easy

• Didn’t have any questions

7. What is the main purpose of the National Children’s Study?

Mark [x] one box.

• To assess the costs of medical care for children and pregnant women

• To help develop better medical schools and training programs for doctors

• To learn what things affect children’s health, growth and development

• To determine how many healthy babies are born each year

8. Do you have to participate in the National Children’s Study?

• No, it is my choice whether I participate or not.

• Yes, I must participate since my community is part of the study.

• Not sure

9. If you become pregnant and have a baby, how long would the National Children’s Study like you and your child to participate in the study?

Mark [x] one box.

• Just while I am pregnant

• Until my child’s first birthday

• Until my child starts school

• Until my child reaches age 18 or finishes high school

• Until my child reaches age 21

• Not sure

10. True or false: In order to participate in the National Children’s Study, you must sign a consent form indicating that you agree to participate.

• True

• False

11. Are you of Hispanic or Latino origin?

• Yes

• No

12. What is your race?

Select one or more.

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or Other Pacific Islander

13. What is the highest grade or level of school that you have completed?

Mark [x] one box.

• 8^th grade or less

• Some high school, but did not graduate

• High school graduate or GED

• Some college or associate’s degree

• Bachelor’s degree

• Graduate or professional degree beyond a bachelor’s degree.

14. Are you…

• Less than 25 years of age,

• 25 to 29,

• 30 to 34,

• 35 to 39, or

• 40 or older?

15. Please share any other comments you have about the video the study representative showed you today:

-- PLEASE COMPLETE THE LAST FEW QUESTIONS ON THE NEXT PAGE –

Thank you for sharing your opinion with us. Your responses will help us improve the video and other related materials as the study continues.

National Children’s Study

Consent Questionnaire

Instructions

Please use a black or blue pen to complete this form.

Mark [X] to indicate your answer.

If you want to change your answer, mark [X] on the wrong answer.

Put your completed questionnaire in the envelope and return it to the interviewer.

 The following questions ask for your opinion on the booklet you reviewed earlier with the Study interviewer titled “Making an Informed Choice about being in the National Children’s Study”.

1. In your opinion, how much of the information in the booklet did you need to know to decide whether to participate in the study?

• None of it

• Some of it

• Most of it

• All of it

2. In your opinion, how much of the information in the booklet was easy to understand?

• None of it

• Some of it

• Most of it

• All of it

3. Overall, do you think the booklet provided…

• Too much detail,

• About the right amount of detail, or

• Not enough detail?

4. In general, how interesting did you find the booklet when reading it and discussing it with the study representative?

• Not at all interesting

• A little interesting

• Somewhat interesting

• Very interesting

5. Do you think the amount of time it took to review the booklet was…

• Far too long,

• A little too long,

• About the right amount of time,

• A little too short, or

• Far too short?

6. In general, how difficult or easy was it to ask questions or get more information about something reviewed in the booklet?

• Very difficult

• Somewhat difficult

• Somewhat easy

• Very easy

• Didn’t have any questions

7. What is the main purpose of the National Children’s Study?

Mark [x] one box.

• To assess the costs of medical care for children and pregnant women

• To help develop better medical schools and training programs for doctors

• To learn what things affect children’s health, growth and development

• To determine how many healthy babies are born each year

8. Do you have to participate in the National Children’s Study?

• No, it is my choice whether I participate or not.

• Yes, I must participate since my community is part of the study.

• Not sure

9. If you become pregnant and have a baby, how long would the National Children’s Study like you and your child to participate in the study?

Mark [x] one box.

• Just while I am pregnant

• Until my child’s first birthday

• Until my child starts school

• Until my child reaches 18 or finishes high school

• Until my child reaches 21

• Not sure

10. True or false: In order to participate in the National Children’s Study, you must sign a consent form indicating that you agree to participate.

• True

• False

11. Are you of Hispanic or Latino origin?

• Yes

• No

12. What is your race?

Select one or more.

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or Other Pacific Islander

13. What is the highest grade or level of school that you have completed?

Mark [x] one box.

• 8^th grade or less

• Some high school, but did not graduate

• High school graduate or GED

• Some college or associate’s degree

• Bachelor’s degree

• Graduate or professional degree beyond a bachelor’s degree

14. Are you…

• Less than 25 years of age,

• 25 to 29,

• 30 to 34,

• 35 to 39, or

• 40 or older?

15. Please share any other comments you have about the booklet you reviewed with the study representative today:

Thank you for sharing your opinion with us. Your responses will help us improve the booklet and other related materials as the study continues.

National Children’s Study

Consent Questionnaire

Instructions

Please use a black or blue pen to complete this form.

Mark [X] to indicate your answer.

If you want to change your answer, mark [X] on the wrong answer.

Put your completed questionnaire in the envelope and return it to the interviewer.

1. About how much of the video called “Making an Informed Choice about being in the National Children’s Study” did you watch today?

• None of it Skip to question 5.

• 10 minutes or less

• 11 to 20 minutes

• 21 to 30 minutes

• All of it

2. In your opinion, how much of the information in the video was easy to understand?

• None of it

• Some of it

• Most of it

• All of it

3. Do you think the amount of time it took to watch the video was…

• Far too long,

• A little too long,

• About the right amount of time,

• A little too short, or

• Far too short?

4. Did you think about any of the information explained in the video when deciding whether you wanted to take part in the National Children’s Study?

• Yes

• No

5. 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

• Valuable

• Very valuable

6. In your opinion, what is the main purpose of the National Children’s Study?

Mark [x] one box.

• To assess the costs of medical care for children and pregnant women

• To help develop better medical schools and training programs for doctors

• To learn what things affect children’s health, growth and development

• To determine how many healthy babies are born each year

7. Why did you decide not to take part in the National Children’s Study?

Mark [X] all that apply.

• I think the information collected in this study is too personal.

• Taking part would require too much of my time.

• I don’t believe that the information collected in this study can actually help children.

• I don’t believe the study staff can really keep my information confidential.

• I don’t want to commit to something for 21 years.

• I don’t think my husband, partner or family will want me to do this.

• I did not feel comfortable with the interviewer.

• I don’t want anyone from the study staff visiting my home or calling me.

• I don’t want the study staff to have access to my personal health information or my child’s.

• I don’t want the study staff to examine me or my child.

• I don’t want the study staff to take any air, water, soil or dust samples from my yard or home.

• Please list any other reasons: 

___________________________________________________________

___________________________________________________________

8. Are you of Hispanic or Latino origin?

• Yes

• No

9. What is your race?

Select one or more.

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or Other Pacific Islander

10. What is the highest grade or level of school that you have completed?

Mark [x] one box.

• 8^th grade or less

• Some high school, but did not graduate

• High school graduate or GED

• Some college or associate’s degree

• Bachelor’s degree

• Graduate or professional degree beyond a bachelor’s degree

11. Are you…

• Less than 25 years of age,

• 25 to 29,

• 30 to 34,

• 35 to 39, or

• 40 or older?

Thank you for taking the time to answer these questions about your experience today.

National Children’s Study

Consent Questionnaire

Instructions

Please use a black or blue pen to complete this form.

Mark [X] to indicate your answer.

If you want to change your answer, mark [X] on the wrong answer.

Put your completed questionnaire in the envelope and return it to the interviewer.

1. About how much of the booklet called “Making an Informed Choice about being in the National Children’s Study” did you and the study interviewer read through today?

• None of it Skip to question 5.

• Some of it

• Most of it

• All of it

2. In your opinion, how much of the information in the booklet was easy to understand?

• None of it

• Some of it

• Most of it

• All of it

3. Do you think the amount of time it took to review the booklet was…

• Far too long,

• A little too long,

• About the right amount of time,

• A little too short, or

• Far too short?

4. Did you think about any of the information explained in the booklet when deciding whether you wanted to take part in the National Children’s Study?

• Yes

• No

5. 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

• Valuable

• Very valuable

6. In your opinion, what is the main purpose of the National Children’s Study?

Mark [x] one box.

• To assess the costs of medical care for children and pregnant women

• To help develop better medical schools and training programs for doctors

• To learn what things affect children’s health, growth and development

• To determine how many healthy babies are born each year

7. Why did you decide not to take part in the National Children’s Study?

Mark [X] all that apply.

• I think the information collected in this study is too personal.

• Taking part would require too much of my time.

• I don’t believe that the information collected in this study can actually help children.

• I don’t believe the study staff can really keep my information confidential

• I don’t want to commit to something for 21 years.

• I don’t think my husband, partner or family will want me to do this.

• I did not feel comfortable with the interviewer.

• I don’t want anyone from the study staff visiting my home or calling me.

• I don’t want the study staff to have access to my personal health information or my child’s.

• I don’t want the study staff to examine me or my child.

• I don’t want the study staff to take any air, water, soil or dust samples from my yard or home.

• Please list any other reasons: 

___________________________________________________________

___________________________________________________________

8. Are you of Hispanic or Latino origin?

• Yes

• No

9. What is your race?

Select one or more.

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or Other Pacific Islander

10. What is the highest grade or level of school that you have completed?

Mark [x] one box.

• 8^th grade or less

• Some high school, but did not graduate

• High school graduate or GED

• Some college or associate’s degree

• Bachelor’s degree

• Graduate or professional degree beyond a bachelor’s degree

11. Are you…

• Less than 25 years of age,

• 25 to 29,

• 30 to 34,

• 35 to 39, or

• 40 or older?

Thank you for taking the time to answer these questions about your experience today.