Amazing Me-It's Busy 3! Book Survey

Attachment A Form Approved

OMB No. 0920-0919

Exp. Date 01/31/2015

Amazing Me- It’s Busy Being 3! Book Survey

(Draft 10-24-12)

Thank you for your interest in this study and your willingness to participate. Your privacy is very important to us. Your responses to all questions will be kept secure. You will not be asked to provide any personal identifying information. Only people working on this study will have access to survey responses. Your participation is completely voluntary, but the information you provide will ensure that experiences like yours are represented. You may choose to exit the survey at any time.

1. I have read and understand this information and agree to participate:

• Yes

• No. I do not want to participate at this time. [GO TO THANK4]

2. What is the name of the clinic you represent?

__________________________________________

[TO BE ASKED AT SURVEY 1 ONLY.]

3. Please confirm that your clinic received the book, Amazing Me- It’s Busy Being 3!, in the spring of 2012?

Yes, we received 300 books (3 boxes of 100 each)
Yes, our clinic did receive the books, but I’m not sure how many books we received.
No, we did not receive the books.	GO TO THANK3

Book Tracking Questions [TO BE ASKED AT ALL SURVEY ADMINISTRATIONS.]

4. Today, about how many copies of Amazing Me- It’s Busy Being 3! does your clinic have left? (Each unopened box contains 100 books)

0	GO TO 6
1-50	GO TO 6
51-100	GO TO 4
101-150	GO TO 4
151-200	GO TO 4
201-250	GO TO 4
251-300	GO TO 4

5. Does your clinic intend to distribute at least some of the remaining books over the next 6 months?

Yes	GO TO 7
No	GO TO 6

6. Please tell us some reasons that your clinic does not intend to distribute the remaining copies of Amazing Me?

_______________________________________

7. Approximately what percentage of the books you’ve distributed were given to parents of 3-year-olds, as opposed to older or younger children?

0-25%

26-50%

51-75%

76-100%

Programming Note

If 3 =0, 1-50, or

IF FOLLOW-UP 2, GO TO 8

ELSE, GO TO THANK1 THEN THANK 4

Book Distribution Experience Questions

8. About how long did it take your clinic to distribute the Amazing Me books you received?

1. Less than 1 month

2. 1-2 months

3. 3-5 months

4. 6+ months

9. Who was the person in your clinic who typically distributed Amazing Me books to parents?

Doctor, Physician Assistant, or Nurse Practitioner
Nurse or Nurse Assistant
Front Desk Staff
Other	GO TO OS
(OS) Please describe the title of the person who typically gave Amazing Me books to parents: ___________________________________

10. Typically, at what point during the visit did parents receive the book?

At check in
While in the waiting room before the visit
In the exam room
At check out
Other	GO TO OS
(OS) Please describe when or where you distributed Amazing Me books to parents. ________________

11. How often did doctors/nurses at your clinic review or discuss the book with parents?

All of the time
More than half of the time
Less than half of the time
Not at all

12. Overall, how difficult was it to distribute a copy of Amazing Me to every parent of a 3-year-old seen in your clinic?

Very difficult	GO TO 13
Somewhat difficult	GO TO 13
Not too difficult	GO TO 14
Not at all difficult	GO TO 14

13. What are some reasons it was difficult to distribute a copy of Amazing Me to every parent of a 3-year-old seen in your clinic?

_________________________________________ (GO TO 15)

14. Please describe particular strategies that your clinic found helpful in distributing the Amazing Me book to every parent of a 3-year-old seen in your clinic?

_________________________________________

15. Compared to how you typically distribute other Reach Out and Read books, was there anything different about how your clinic distributed Amazing Me?

Yes	GO TO 16
No	GO TO 17

15. Please describe some differences in how your clinic distributed the Amazing Me book, compared to how you typically distribute other Reach Out and Read books. Why?

_________________________________________

15. Compared to how you typically talk about other Reach Out and Read books with parents, was there anything different about how your clinic discussed Amazing Me?

Yes	GO TO 18
No	GO TO 19

15. Please describe some differences in how your clinic discussed the Amazing Me book with parents, compared to how you typically discuss other Reach Out and Read books. Why?

_________________________________________

15. How would you describe doctors’/nurses’ responses to Amazing Me, compared to other Reach Out and Read books?

More favorable	GO TO 20
Less Favorable	GO TO 21
About the same	GO TO 22
Not sure	GO TO 22

15. Please list some reasons doctors/nurses have responded more favorably to Amazing Me, compared to other books your clinic has distributed?

___________________________________________ (GO TO 22)

15. Please list some reasons doctors/nurses have responded less favorably to Amazing Me, compared to other books your clinic has distributed?

___________________________________________

15. How would you describe overall feedback from parents about Amazing Me, compared to other books your clinic has distributed?

More favorable	GO TO 24
Less Favorable	GO TO 23
About the same	GO TO 24
Not sure	GO TO 24

15. Please list some reasons parents have responded less favorably to Amazing Me, compared to other books your clinic has distributed?

___________________________________________

15. Would your clinic like to continue to distribute the Amazing Me books to parents?

Yes
No	GO TO 26

15. Would your clinic consider purchasing Amazing Me in order to have more copies to distribute to parents?

Yes
No

15. Based on your experience distributing the Amazing Me book, do you think it facilitated more discussion between parents and doctors/nurses about their children’s development and various milestones?

Yes	GO TO THANK2
No	GO TO 27

15. What are some reasons you think the Amazing Me book did not promote discussion among parents and doctors/nurses about their children’s development and various milestones?

__________________________________________ GO TO THANK2

THANK1: We will follow-up with you again in about 6 weeks to ask a few more questions about the books you have distributed and the ones you have remaining. Completing this survey has entered your clinic in a drawing for 50 popular board books.  The drawing will be done at the close of the survey.  If your clinic wins the drawing, you will be contacted via email.

THANK2: The time you’ve spent both distributing the books in your office and completing this survey has been very important to this research effort. Your responses will be very helpful to future efforts to distribute Amazing Me-It’s Busy Being 3! Completing this survey has entered your clinic in a drawing for 50 popular board books.  The drawing will be done at the close of the survey.  If your clinic wins the drawing, you will be contacted via email.

THANK3: We are sorry to learn that your clinic did not receive the 300 free copies of Amazing Me-It’s Busy Being 3! that it was intended. If you would still like to receive these books, please contact Katie Green at [email protected] and include the appropriate shipping address.

[ALL: THANK4]: Thank you for your time. Have a nice day.

The public reporting burden of this collection of information is estimated to average 5 minutes per response, 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 (0920-0919)