3 Screener for Parents for Post Implemention Survey-Englis

Evaluating Reach, Awareness, and Exposure of Enhanced Implementation of the Learn the Signs. Act Early. Campaign in Four Target Sites

Att 3A Screener for Parents (English) 9 9 11

Screener for Parents for Post-Implementation Survey

OMB: 0920-0911

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LTSAE Attachment 3a

Form Approved

OMB No.: 0920-XXXX

Exp. Date: _____________















A Screener FOR PARENTS

Learn thE signs. Act Early.”



















Screener



Survey administrator (script):

Would you be willing to complete a survey for us? It should only take 10 minutes to complete.

  1. Do you have a child who is 5 years old or younger?

If yes -> Continue to next question

If no -> Thank and end



  1. What language would you prefer for a survey?

English & Spanish -> Continue with English or Spanish survey

If other -> Thank and end







Public reporting burden of this collection of information is estimated to average 3 minutes 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-11EX).

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleLTSAE
Authorbzheng
File Modified0000-00-00
File Created2021-01-31

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