Form Mail Screener Mail Screener Mail Screener

Appendix C:
Screener Instrument

U.S. Consumer Product
Safety Commission
Survey of Nursery Products
► The U.S. Consumer Product Safety Commission is interested in learning about how U.S.
households think about and use different types of children’s products in their homes. We will
follow-up with a sample of households to get their thoughts on the children’s products they have used
previously or currently have in their homes. Return this form even if there are no children younger than 6
living at this address.
1. Are there any infants, toddlers, or children living at this address?

Yes

No → go to box A, at bottom of the next page

2. Are any of the children living at this address younger than 6 years old?

Yes
No → go to box A, at bottom of the next page

3. Please tell us the first name or initials of the adult living at this address who is most familiar with
children’s products in your home. We may follow-up with this person to find out more about the
children’s products in your home, if this address is selected to participate in the survey.

First Name:

Please continue on the next page →

*123456*
57483

4. What is the best telephone number for
contacting the person you identified above?

-

-

5. Is that number...

personal cell phone?

home landline?

business phone?

Other

6. If available, what is the best email address to contact the person you identified above?

Mark if no email address is available

7. What is the best way to reach the person you identified?

Telephone

Email

Both

Thank you for your time. Westat, the company conducting the
survey for us, will be in contact in a few weeks to conduct the
survey. Please return this form in the postage-paid envelope
provided.

A. It is important that we receive a response from
every household selected for this study. If you
marked in question 1 that you had no infants,
toddlers or children living in your household
OR if you marked in question 2 that no one in
your household is younger than 6, you have
completed this form. Please return this form in
the enclosed postage-paid envelope.

Thank you for your time.

*123456*
57483