Parent Survey - Word

Form Approved

OMB NO. 0920-XXXX

Exp. Date: xx/xx/xxxx

Attachment 3

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

T hank you for your interest in this survey. The Centers for Disease Control and Prevention (CDC) would like to learn what parents think about the book Amazing Me-It’s Busy Being 3! This survey should take about 10 minutes. Your privacy is very important to us.

Your responses to all questions will be kept secure. You will not be required 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 share will help make sure that opinions like yours are included the study. You may choose to leave the survey at any time. Please answer a few questions to see if you are eligible to take the survey. If you are eligible, you will receive a $5 online gift card to Target or Wal-Mart upon completion of the survey.

1. [MANDATORY] I have read and understand this information and agree to participate in this survey.

1. Yes

2. No. I do not want to participate at this time GO TO THANK2

2. Are you 18 years of age or older?

1. Yes

2. No  GO TO THANK1

3. Are you the parent or guardian of a child who is age 3, will soon be age 3, or recently turned 4?

a. Yes

b. No  GO TO THANK1

4. Just to confirm, did you receive a copy of the book, Amazing Me--It’s Busy Being 3! from your child’s doctor’s office?

1. Yes

2. No  GO TO THANK1

3. Don’t remember  GO TO THANK1

5. Have you read the book, Amazing Me?

1. Yes

2. No GO TO THANK1

THANK1: Thank you for your time. We are sorry, but you are not eligible for the survey. If you’d like more information about Amazing Me, please visit: http://www.cdc.gov/ncbddd/actearly/amazingme.html Have a nice day.

THANK2: Thank you. If you’d like more information about Amazing Me, please visit: http://www.cdc.gov/ncbddd/actearly/amazingme.html

Survey

1. Book Receipt Confirmation

6. Thinking back to when you received the book, Amazing Me, from your child’s doctor’s office, who handed you the book?

1. The child’s doctor

2. A nurse

3. Someone from the front desk

4. Someone else (Please specify):________________

7. About how long ago did you receive the book?

1. Within the last week

2. A few weeks ago

3. More than a month ago

2. Book Experience

8. Have you read the book, Amazing Me, to your child?

1. Yes  GO TO 11

2. No

9. What are some reasons you haven’t yet read the book to your child? (Please select all that apply):

1. Haven’t had time

2. Didn’t like the book

3. Lost the book

4. Don’t read at home

5. Other: ____________

10. How likely are you to read Amazing Me to your child?

1. Very likely

2. Somewhat likely

3. Not very likely

4. Not at all likely

11. Did you read the introduction note at the beginning of the book?

1. Yes

2. No

3. No, but I plan to

12. Did you read the “Milestone Moments” at the bottom of most pages?

1. Yes

2. No

3. No, but I plan to

13. Did you read the main story about Joey?

1. Yes

2. No

3. No, but I plan to

14. Did you read the developmental milestones section at the end (p27-30)?

1. Yes

2. No

3. No, but I plan to

3. Book Content and Format

15. Please select how much you agree or disagree with the following statements.

	Strongly Agree	Agree	Disagree	Strongly Disagree
Overall, I enjoyed reading the book.	1	2	3	4
Some of the information in the book for parents was confusing or unclear.	1	2	3	4
This book taught me something new about how young children develop.	1	2	3	4
I liked learning about how young children develop through a children’s book.	1	2	3	4
I would like to receive other books like this about children’s developmental milestones for other ages.	1	2	3	4

16. Please select how much you agree or disagree with the following statement.

Overall, my child enjoyed the book.

Strongly Agree	GO TO Q18
Agree	GO TO Q18
Disagree
Strongly Disagree
I did not read the book to my child	GO TO Q18

17. What are some reasons why you think your child did not like the book? Select all that apply:

1. The story was too long

2. The story was too difficult to understand

3. My child likes other books better

4. My child didn’t like the character, Joey

5. The story did not keep my child’s attention

6. Other: ________

IV. Book Influence

We’d like to learn more about how the book, Amazing Me, has influenced parents. Please tell us how much you agree or disagree with the following statements:

18. As a result of reading the book Amazing Me I learned something new about developmental milestones.

1. Strongly Agree

2. Agree

3. Disagree

4. Strongly Disagree

19. The information I learned in the book Amazing Me has me thinking more about how my child is growing and developing.

1. Strongly Agree

2. Agree

3. Disagree

4. Strongly Disagree

20. The information in the book Amazing Me encouraged me to look for developmental milestones in my child.

1. Strongly Agree

2. Agree

3. Disagree

4. Strongly Disagree

21. The information I learned in the book Amazing Me made me feel that it is important to talk with my child’s doctor about whether his/her development is on track for his/her age.

1. Strongly Agree

2. Agree

3. Disagree

4. Strongly Disagree

22. Please select whether or not you have done the following things after reading Amazing Me:

	Yes	No	No, but I plan to
I have used the Developmental Milestones for 3-year-olds checklist at the back of the book to check my child’s growth and development.	1	2	3
Since reading the book I have talked with others about developmental milestones.	1	2	3
Since reading the book, I have talked with my child’s doctor about my child’s developmental milestones.	1	2	3
Since reading the book, I have looked for more information about developmental milestones.	1	2	3

Demographics

23. What is your age range?

1. 20 or under

2. 21-30

3. 31-40

4. 41-50

5. 50 plus

24. What is your gender?

1. Male

2. Female

25. Are you of Hispanic or Latino origin?

1. Yes

2. No

26. What is your race/ethnicity? (please select all that apply)

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

6. Refused

27. What is the highest level of education you have completed?

1. Less than high school

2. High school diploma or GED

3. Technical college/Associates degree

4. Some college

5. College degree

6. Graduate degree

28. Which best describes your total household income?

1. Under $15,000

2. $15,000-$24,999

3. $25,000-$34,999

4. $35,000-$49,999

5. Over $50,000

29. Is the doctor’s office where you received Amazing Me the same doctor’s office you USUALLY go to when your child is sick or you need advice about his/her health? 

1. Yes  GO TO END

2. No  GO TO Q30

30. Where does your child USUALLY go when he/she is sick or you need advice about his/her health?

1. Doctor’s Office

2. Emergency Room

3. Urgent Care

4. Hospital Outpatient Department

5. Clinic (including Public Health Clinic or Vaccine Clinic)

6. Some other place: _________

Thank you for completing this survey. To receive your $5 Target or Wal-Mart gift card, please click the link below. If you do not want to receive a gift card, please click “done.” [DIRECT PARTICIPANTS TO LINK TO CONTACT INFO SURVEY]

Public reporting burden of this collection of information is estimated to average 10 minutes, 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)