Formative - Developmental

ATTACHMENT B.2.4 LOI2-PHYS-15 EXEMPLAR PARTICIPANT EXPERIENCE SURVEY OMB #: 0925-0593

EXPIRATION DATE: 07/31/2013

Research Participant Experience Survey

The purpose of this survey is to discover ways we can help improve your experience as a participant in this research project.

We would like ask you a few questions about your experience participating in the research visit today. There are no right or wrong answers. You can refuse to answer any question or group of questions, and your answers will be kept confidential.

1. How important to you was each of the following during your visit today?

How important was…

	Not at all Important	Somewhat Important	Very Important
Feeling comfortable with study staff?			
Receiving money or gifts for taking part in the study?			
Helping doctors and researchers learn more about children and their development?			
Having the study staff respect my rights and my child’s rights as an individual?			

2. How stressful for you and your baby was each of the following during your visit today?

How stressful was…

	Not at all stressful	Somewhat stressful	Very stressful
Having study staff conduct a physical examination of my baby?			
Having study staff take photographs of my baby?			
Having study staff take videos of my baby?			

Research Participant Experience Survey

3. Did you think the study visit was

 Too long

 Too short, or

 Just about right?

4. In general, was your experience with your study visit

 Mostly negative,

 Somewhat negative,

 Neither negative nor positive,

 Somewhat positive, or

 Mostly positive?

5. Do you have any suggestions on what we can do to help improve your experience as a participant in this research project? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for participating in this research project and for taking the time to complete this survey.

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.