Follow-up Survey - Word

Form Approved

OMB NO. 0920-XXXX

Exp. Date: xx/xx/xxxx

Attachment 4: Amazing Me- It’s Busy Being 3! Parent Follow-up Contact Survey

CONTACT INFORMATION QUESTIONS

1. Please enter the ID number located on the sticker on the book cover: _________

2. Would you like to receive a gift card as an incentive?

   1. Yes

   2. No

3. To receive your $5 online Target or Wal-Mart gift card, please provide your email address. If you do not have an email address please proceed to question #4 to enter your postal address. (Please note: The personal information you provide here will NOT be linked to your responses in the survey.):

1. EMAIL:_______

EMAIL AGAIN:______[GO TO 5]

4. To receive your $5 gift card in the mail, please share your mailing information.

1. NAME: _________

STREET:______

CITY: _______

STATE: _______

ZIP: _______

5. Would you like to receive $40 by participating in a group discussion with parents like you in your community (name, phone number, and/or email address required)?

1. Yes  GO TO Q6

2. No  GO TO THANK2

6. In order to learn if you are eligible to participate please enter your contact information below. A researcher from Westat will be in touch about scheduling the group discussion.

NAME:

PHONE:

Please enter your email address below:

EMAIL:

EMAIL AGAIN:

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

Public reporting burden of this collection of information is estimated to average 1 minute, 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)