3c LTSAE ATT3C Pre-Implementation Survey for Parents (Engli

LTSAE Attachment 3c

Form Approved

OMB No.: 0920-XXXX

Exp. Date: _____________

A Pre-implementation SURVEY FOR PARENTS

“Learn thE signs. Act Early.”

Pre-Implementation Parent Survey

Thank you again for agreeing to complete this survey. Completing this survey is completely voluntary. Please do not put your name anywhere on the survey because your answers are anonymous. You may skip any question that you do not feel comfortable answering.

1. How many children 5 years old or younger do you have? _________

2. As of today, how old is your youngest child? _________

3. Did you hear of the “Learn the Sign. Act Early.” campaign BEFORE [ENHANCED CAMPAIGN LAUNCH DATE]?

c Yes c No

4. The “Learn the Signs. Act Early” campaign is about which one of the following topics? [select only one]

c Breast Cancer

c Child Development

c Stroke

c HIV/AIDS

c Type II Diabetes

c Autism

5. Where did you see/hear about the “Learn the Signs. Act Early.” campaign BEFORE [ENHANCED CAMPAIGN LAUNCH DATE]? [select all that apply]

c TV

c Radio

c Internet/Online

c Doctor’s Office

c My Child’s Teacher or Child care Provider

c Family Member/Friend

• A Program in My Community (e.g. WIC office, library, community center, health fair)

• Magazine

• Newspaper

• Advertising

• I don’t remember

• Other (Please specify_________)

6. Have you seen or heard anything about developmental milestones (things to look for in your child to tell if he is on track for his age?) BEFORE [ENHANCED CAMPAIGN LAUNCH DATE]?

c Yes c No (If No, please go directly to Question 8)

7. Where did you see/hear about developmental milestones BEFORE [ENHANCED CAMPAIGN LAUNCH DATE]? (things to look for in your child to tell if he is on track for his age?) [select all that apply]

c TV

c Radio

c Internet/Online

c Doctor’s Office

c My Child’s Teacher or Child care Provider

c Family Member/Friend

• A Program in My Community (e.g. WIC office, library, community center, health fair)

• Magazine

• Newspaper

• Advertising

• I don’t remember

c Other (Please specify_________)

8. What is your zip code? _ _ _ _ _

9. How old are you?

c Under 21 years old

• 21 – 34

• 35 – 45

• 46 or older

10. Do you identify yourself as Hispanic or Latino?

c Yes, Hispanic or Latino

c No, Not Hispanic or Latino

11. Which of these groups would you say best represents your race? (Please select all that apply)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

12. What is the highest level of education you have completed?

• Less than high school, no diploma

• High school diploma or GED

• Associate degree or some college (for example: AA, AS)

• Bachelor’s degree or more (for example: BA, BS, MPH, PhD)
  
  

13. What is your annual household income before taxes?

• Less than $15,080

• $15,081 - $20,080

• $20,081 - $31,200

• $31,201 - $41,600

• $41,601 and above

• Unemployed

(Questions 14-18) If you became concerned about your child’s development (how your child plays, learns, speaks, or acts), how likely would you be to do each of the following?
(Circle one number for each statement)

14. Wait for a few (1–3) months to see if your concerns are resolved.

Not at all likely 1 2 3 4 Extremely likely

15. Wait for 6 months or more to see if your concerns are resolved.

Not at all likely 1 2 3 4 Extremely likely

16. Talk with your child’s doctor about your concerns as soon as possible.

Not at all likely 1 2 3 4 Extremely likely

17. Talk with your child’s teacher or child care provider as soon as possible.

Not at all likely 1 2 3 4 Extremely likely

• Not applicable (if your child does NOT have a teacher or child care provider)

18. Contact your local intervention program, school, or another local organization as soon as possible.

• Not at all likely 1 2 3 4 Extremely likely

19. If you became concerned about your child’s development (how your child plays, learns, speaks, or acts), when would you contact your child’s doctor to discuss your concern?
[select only one]

• I would not contact my child’s doctor about these concerns.

• I would continue to watch my child’s development for a few months before contacting my child’s doctor.

• I would discuss my concern at my child’s next regularly scheduled doctor appointment.

• I would make a special appointment to talk with my child’s doctor if my child’s next regularly scheduled appointment was more than a month away.

20. Have you looked somewhere (for example, in a book, at a fact sheet, or on a website) to make sure your child’s development (how your child plays, learns, speaks, and acts) is on track for his or her age?

c Yes c No

21. Do you talk to your child’s doctor or nurse about your child’s development (how your child plays, learns, speaks, and acts)? (Circle one number)

Strongly disagree 1 2 3 4 Strongly Agree

Thank you for your time!

Public reporting burden of this collection of information is estimated to average 10 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-XXXX).