Form Focus Group-2 Focus Group-2 Focus Group: Participant Information Form (Pregnant Wome

OMB Control No: 0915-xxx

E

xpiration Date: xx-xx-20xx

TEXT4BABY PARTICIPANT INFORMATION (IF YOU ARE PREGNANT)

Thank you for coming to talk with us today about text4baby. Before we begin talking, please take a few minutes to answer the questions below. We will not share any personal information. We will use information from this form to describe the groups of women we spoke with this week.

1. About how long ago did you sign up for text4baby messages?

MARK ONLY ONE

1 □ In the past 2 months

2 □ Between 3 and 4 months ago

3 □ Between 5 and 6 months ago

4 □ More than 6 months ago

5 □ I don’t know

2. About how far along in your pregnancy were you when you signed up for text4baby?

MARK ONLY ONE

1 □ 3 months or less

2 □ 4 to 6 months

3 □ 7 to 9 months

4 □ I don’t know

3. When you decided to sign up for text4baby, how important were each of the following reasons?

MARK ONE BOX PER ROW

Reason	Very Important	Somewhat Important	Not Very Important
The messages are free.	□	□	□
The messages are convenient.	□	□	□
My doctor or midwife suggested I sign up.	□	□	□
A friend or family member suggested I sign up.	□	□	□
I wanted to get tips about having a healthy baby.	□	□	□
I wanted to get phone numbers to call for information about specific health topics.	□	□	□
I thought the reminders about prenatal care and other appointments would be helpful.	□	□	□

4. How often do you read your text4baby messages?

MARK ONLY ONE

1 □ Always

2 □ Usually

3 □ Sometimes

0 □ Never

5. How often do you learn something new from text4baby messages?

MARK ONLY ONE

1 □ Always

2 □ Usually

3 □ Sometimes

0 □ Never

6. How often do you share text4baby messages with friends or relatives?

MARK ONLY ONE

1 □ Always

2 □ Usually

3 □ Sometimes

0 □ Never

7. Have you ever called a phone number included in a text4baby message?

MARK ONLY ONE

1 □ Yes

0 □ No

8. Have you ever looked at the text4baby website or Facebook page?

MARK ONLY ONE

1 □ Yes

0 □ No GO TO QUESTION 10

9. How useful was the information on the tex4baby website or Facebook page?

MARK ONLY ONE

1 □ Very useful

2 □ Somewhat useful

3 □ Not very useful

10. During the past 12 months, have you had a flu shot?

MARK ONLY ONE

1 □ Yes

0 □ No

11. Did text4baby help you decide whether or not to get a flu shot?

MARK ONLY ONE

1 □ Yes

0 □ No

12. During this pregnancy, how many times a week do you take a multivitamin, prenatal vitamin, or folic acid vitamin?

MARK ONLY ONE

1 □ Never

2 □ 1 to 3 times a week

3 □ 4 to 6 times a week

4 □ Every day of the week

13. When your baby is born, do you plan to breastfeed or feed pumped breast milk to your baby?

MARK ONLY ONE

1 □ Yes

0 □ No

14. When your baby is born, how do you plan to lay him or her down to sleep?

MARK ONLY ONE

1 □ Side

2 □ Back

3 □ Stomach

15. Do you have one place where you usually go for your prenatal care?

MARK ONLY ONE

1 □ Yes

0 □ No

2 □ I haven’t gotten any prenatal care

16. During the past 12 months, did you see a dentist for preventive dental care, such as a check-up or dental cleaning?

MARK ONLY ONE

1 □ Yes

0 □ No

17. In general, how would you describe your health?

MARK ONLY ONE

1 □ Excellent

2 □ Very good

3 □ Good

4 □ Fair

5 □ Poor

18. Do you have any kind of health care coverage or insurance to help pay for your health care?

MARK ONLY ONE

1 □ Yes

0 □ No

19. How old are you?

| | | YEARS

20. Are you of Hispanic or Latino origin?

MARK ONLY ONE

1 □ Yes

0 □ No

21. What is your race?

MARK ALL THAT APPLY

1 □ American Indian/Alaska Native

2 □ Asian

3 □ Black or African American

4 □ Native Hawaiian or other Pacific Islander

5 □ White

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0915-xxxx. The time required to complete this information collection is estimated to average 45 minutes per response. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

Thank you for completing this form. The information you provided will help us evaluate the text4baby program.

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