F - Sample Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Attachment F:

EXAMPLE SURVEY

CMV Awareness Survey

INTRODUCTION

Thank you for agreeing to participate in the survey. This survey is being conducted on behalf of the Centers for Disease Control and Prevention (CDC) to learn more about parents’ interactions with young children, views about childhood health conditions, and reactions to information materials CDC is creating for parents. Your answers will help guide future CDC materials and messages to parents.

Please answer questions as honestly as possible. There is no right or wrong answer and all your responses will be secure. This is a voluntary study and you can stop at any time. The survey will take about 15 minutes and if you’re ready to begin, let’s get started.

1. Baseline Awareness/Knowledge of CMV

1. When your youngest child was in diapers, how often did you wash your hands or use hand sanitizer after each of the following?

[RANDOMIZE]

	Never	Rarely	Some of the time	Most of the time	Always
After changing your child’s dirty (poopy) diaper	1	2	3	4	5
After changing your child’s wet (urine only) diaper	1	2	3	4	5
After handling household cleaning products
After wiping your child’s nose	1	2	3	4	5
After handling raw meat
After handling your child’s toys	1	2	3	4	5

2. When your youngest child was in diapers, how often did you do each of the following?

[RANDOMIZE]

	Never	Rarely	1-2 days a week	3-5 days a week	Every day
Share food with your child (take bites from the same food)	1	2	3	4	5
Share the same cup with your child	1	2	3	4	5
Share eating utensils (knife, fork, or spoon) with your child	1	2	3	4	5
Take vitamins, including folic acid supplements	1	2	3	4	5
Kiss your child on their lips	1	2	3	4	5
Drink caffeinated beverages (including soda, coffee, tea)	1	2	3	4	5
Share towels or washcloths with your child	1	2	3	4	5
Scoop or change a cat litter box	1	2	3	4	5
Share a toothbrush with your child	1	2	3	4	5
Put a pacifier in your mouth after it has been in your child’s mouth	1	2	3	4	5
Eat uncooked or undercooked meat (e.g., sushi, rare or medium rare hamburger or steak)	1	2	3	4	5
Clean toys that come in contact with your child’s mouth	1	2	3	4	5

3. Please indicate how familiar you are with each of the following health conditions.

[RANDOMIZE]

	Very familiar	Somewhat familiar	Not very familiar	Not at all familiar
Congenital rubella syndrome	1	2	3	4
Beta strep (Group B strep)	1	2	3	4
HIV/AIDS	1	2	3	4
Congenital cytomegalovirus (CMV)	1	2	3	4
Down syndrome	1	2	3	4
Sudden infant death syndrome (SIDS)	1	2	3	4
Fetal alcohol syndrome	1	2	3	4
Autism	1	2	3	4
Spina bifida	1	2	3	4
Congenital toxoplasmosis (toxo)	1	2	3	4
Parvovirus B19 (Fifth disease)	1	2	3	4

The following questions will focus on a specific birth defect, congenital cytomegalovirus commonly referred to as CMV.

For the following question, please rank in order of most likely to least likely.

4. A pregnant woman is most likely to catch CMV from:

[RANDOMIZE]

	Most likely		Least likely
Toddler	1	2	3
Partner or spouse	1	2	3
Teenager	1	2	3

5. Please indicate how much you agree with each of the following statements. [RANDOMIZE]

	Strongly Agree	Agree	Disagree	Strongly Disagree
CMV can cause serious disabilities in an unborn child	1	2	3	4
CMV can cause serious disabilities to a woman who is pregnant	1	2	3	4
CMV can spread through urine	1	2	3	4
CMV can spread through saliva	1	2	3	4
CMV can cause heart defects	1	2	3	4
CMV can spread by casual contact with someone	1	2	3	4
CMV can cause hearing loss	1	2	3	4
CMV is about as common as Down Syndrome	1	2	3	4
CMV can spread through feces (poop)	1	2	3	4
If I were pregnant I would be worried about CMV	1	2	3	4
CMV is preventable	1	2	3	4
CMV can spread through hugging or cuddling	1	2	3	4

[PLEASE RANDOMIZE THE ORDER OF PRESENTATION FOR MATERIAL #1 AND #2.]

II. CMV Materials: Message Appeal and Understanding

Next, you’ll be presented with two different information materials about CMV that you might see at a doctor’s office or on the web. You’ll be asked a few questions after viewing each one.

1. CMV Material 1: [EMBED FACTSHEET]

6. Are you able to see the image?

YES	CONTINUE
NO	NOT COUNTED AS COMPLETE AND TERMINATE

Please take a few minutes to read the factsheet and then hit Continue.

7. Thinking about the factsheet you just read, please indicate your level of agreement, where 1=strongly agree and 4=strongly disagree, with each of the following statements.

[RANDOMIZE]

	Strongly Agree	Agree	Disagree	Strongly Disagree
I thought the factsheet was difficult to understand.	1	2	3	4
The information in the factsheet doesn’t apply to me	1	2	3	4
If I were pregnant I would definitely make some changes as a result of viewing this factsheet	1	2	3	4
CMV can cause serious disabilities in an unborn child	1	2	3	4
CMV can cause serious disabilities to a woman who is pregnant	1	2	3	4
CMV can spread through urine	1	2	3	4
CMV can spread through saliva	1	2	3	4
CMV can cause heart defects	1	2	3	4
CMV can spread by casual contact with someone	1	2	3	4
CMV can cause hearing loss	1	2	3	4
CMV is about as common as Down Syndrome	1	2	3	4
If I were pregnant I would be worried about CMV	1	2	3	4
CMV is preventable	1	2	3	4
CMV can spread through hugging or cuddling	1	2	3	4
CMV can spread through feces (poop)	1	2	3	4

If you are not currently pregnant, imagine that you were pregnant when responding to the next two series of questions.

8. Based on what you have just read about CMV in the factsheet, how often do you think you would wash your hands or use sanitizer after each of the following in the future?

[RANDOMIZE]

	Never	Rarely	Some of the time	Most of the time	Always
After wiping your child’s nose	1	2	3	4	5
After handling your child’s toys	1	2	3	4	5
After changing your child’s wet (urine only) diaper)	1	2	3	4	5
After shaking hands with a co-worker	1	2	3	4	5

9. Thinking about what you have just read about CMV in the factsheet, how often do you think you would do each of the following in the future?

[RANDOMIZE]

	Never	Rarely	1-2 days a week	3-5 days a week	Every day
Share food with your child (take bites from the same food)	1	2	3	4	5
Share eating utensils (knife, fork, or spoon) with your child	1	2	3	4	5
Hugging or cuddling your child	1	2	3	4	5
Kiss your child on their lips	1	2	3	4	5

10. What changes would you suggest for the factsheet to improve it?

WRITE IN YOUR RESPONSE___________________________________

2. CMV Material 2: [EMBED VIDEO]

11. Were you able to view and hear the video?

YES	CONTINUE
NO	NOT COUNTED AS COMPLETE AND TERMINATE

Please take a few minutes to listen to the video and then hit Continue.

12. Thinking about the video you just saw, please indicate your level of agreement, where 1=strongly agree and 4=strongly disagree, with each of the following statements.

[RANDOMIZE]

	Strongly Agree	Agree	Disagree	Strongly Disagree
I am not like the person in the video	1	2	3	4
If I were pregnant I would definitely make some changes as a result of viewing this video	1	2	3	4
I thought the video was difficult to understand.	1	2	3	4
CMV can cause serious disabilities in an unborn child	1	2	3	4
CMV can cause serious disabilities to a woman who is pregnant	1	2	3	4
CMV can spread through urine	1	2	3	4
CMV can spread through saliva	1	2	3	4
CMV can cause heart defects	1	2	3	4
CMV can spread by casual contact with someone	1	2	3	4
CMV can cause hearing loss	1	2	3	4
CMV is about as common as Down Syndrome	1	2	3	4
If I were pregnant I would be worried about CMV	1	2	3	4
CMV is preventable	1	2	3	4
CMV can spread through hugging or cuddling	1	2	3	4
CMV can spread through feces (poop)	1	2	3	4

If you are not currently pregnant, imagine that you were pregnant when responding to the next two series of questions.

13. Based on what you have just seen about CMV in the video, how often do you think you would wash your hands or use sanitizer after each of the following in the future?

[RANDOMIZE]

	Never	Rarely	Some of the time	Most of the time	Always
After wiping your child’s nose	1	2	3	4	5
After changing your child’s wet (urine only) diaper	1	2	3	4	5
After handling your child’s toys	1	2	3	4	5
After shaking hands with a co-worker	1	2	3	4	5

14. Thinking about what you have just seen about CMV in the video, how often do you think you would do each of the following in the future?

[RANDOMIZE]

	Never	Rarely	1-2 days a week	3-5 days a week	Every day
Share food with your child (take bites from the same food)	1	2	3	4	5
Share eating utensils (knife, fork, or spoon) with your child	1	2	3	4	5
Kiss your child on their lips	1	2	3	4	5
Hugging or cuddling your child

15. What changes would you suggest for the video to improve it?

WRITE IN YOUR RESPONSE___________________________________

16. In the next week or so, how likely are you to do the following:

	Very likely	Somewhat likely	Not too likely	Not at all likely
Talk to your friends/family about CMV	1	2	4	5
Look for more information about CMV (e.g., talk to your doctor or search the Internet)	1	2	4	5

IV. CMV Information Sources/Channels

The following questions ask about where you might expect to get information about CMV.

17. What do you think might be the best way or most effective channel for educating mothers about CMV?  Please rate how effective each of following channels would be in getting CMV information to mothers like you.

Would you say they are very effective, somewhat effective, not too effective, or not at all effective…

[RANDOMIZE]

	Very effective	Somewhat effective	Not too effective	Not at all effective
Pre-school/child care facility	1	2	3	4
Family/friends	1	2	3	4
Coworkers/neighbors	1	2	3	4
Doctor: OB-GYN
Doctor: Pediatrician	1	2	3	4
Doctor: Primary Care Physician	1	2	3	4
Online: Health information portals (like WebMD)	1	2	3	4
Online: Search engines (like Google, Yahoo)	1	2	3	4
Online: Media sites (like BabyCenter.com, ParentsPlace.com)	1	2	3	4
Online: Social media sites (like Facebook, Twitter, YouTube)	1	2	3	4
Online: Blogs (like Mommy Blogs)	1	2	3	4
Parenting magazines	1	2	3	4
Word-of-mouth recommendations from other mothers	1	2	3	4
Government agencies (like CDC)	1	2	3	4
Other (Specify):_____________	1	2	3	4

Thank you for taking the time to answer these questions. Have a nice day.

The public reporting burden of this collection of information is estimated to average 15 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: OMB (0920-XXXX)