Formative - Developmental

LOI2-PHYS-01 EXEMPLAR EXIT SURVEY ATTACHMENT C.3.8

OMB Number: 0925-0593

Expiration Date: July 31, 2013

STUDY ID: __ __ __ __ __

DATE: __ __ / __ __ / __ __ (dd/mm/yy)

INTERVIEWER: __ __

PARENTAL EXIT SURVEY

“These questions are about the participation of [your child] and you in this study. They will cover final questions regarding your experience while participating. Please answer each question as carefully as possible. ALL INFORMATION THAT YOU GIVE WILL BE KEPT STRICTLY CONFIDENTIAL.”

1) On a scale from 0 to 5, how difficult did you think it was for [your child] to perform the breathing tests during the study?

0 1 2 3 4 5

very easy very hard

2) On a scale from 0 to 5, how stressful did you think it was for [your child] to perform the breathing tests during the study?

0 1 2 3 4 5

not stressful at all extremely stressful

3) On a scale from 0 to 5, how stressful was it for you to have [your child] participate in the study?

0 1 2 3 4 5

not stressful at all extremely stressful

4) On a scale from 0 to 5, how likely would you be to allow [your child] to participate in a study which includes these breathing tests? (Note: It is possible for these tests to be performed at home or in some place other than a doctor's office.)

0 1 2 3 4 5

not likely at all very likely

5) On a scale from 0 to 5, how interested would you be in participating in a study where we call you on the phone every 2-4 months for about a year, to ask if [your child] has had any new respiratory symptoms or problems?

0 1 2 3 4 5

not interested at all very interested

Public reporting burden for 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.