Parent Survey

Att. 3a
Form Approved
OMB NO. 0920-XXXX
Exp. Date: xx/xx/xxxx

Thank 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 less than 5 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 Wal­Mart upon completion of the survey. 

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

j Yes
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n

j No. I do not want to participate at this time.
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n

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)

2. Are you 18 years of age or older?

j Yes
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n
j No
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n

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

j Yes
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n
j No
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n

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?

j Yes
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n
j No
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n

j Don't Remember
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n

5. Have you read the book, Amazing Me?

j Yes
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n
j No
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n

6. Thinking back to when you received the book, Amazing Me, from your child's doctor's
office, who handed you the book?
j The child's doctor
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n
j A nurse
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n

j Someone from the front desk
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n

j Someone else (Please specify):
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n

7. About how long ago did you receive the book?
j Within the last week
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n
j A few weeks ago
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j More than a month ago
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n

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

j Yes
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j No
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n

9. What are some of the reasons you haven't yet read the book to your child? (Please
select all that apply)
c Haven't had time
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e
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g

c Didn't like the book
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g
c Lost the book
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g

c Don't read at home
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g
c  Other:
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g

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

j Somewhat likely
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n
j Not very likely
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n

j Not at all likely
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n

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

j Yes
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j No
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j No, but I plan to
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12. Did you read the "Milestone Moments" at the bottom of most pages?

j Yes
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j No
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j No, but I plan to
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13. Did you read the main story about Joey?

j Yes
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j No
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j No, but I plan to
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14. Did you read the developmental milestones section at the end (p27­30)?

j Yes
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j No
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j No, but I plan to
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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.

j
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n

j
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j
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j
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Some of the information in the book for parents was 

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confusing or unclear.
This book taught me something new about how young 
children develop.
I would like to receive other books like this about 
children's developmental milestones for other ages.

16. Please select how much you agree or disagree with the following statement.
Overall, my child enjoyed the book.
j Strongly agree
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n
j Agree
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n

j Disagree
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n

j Strongly disagree
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j I did not read the book to my child
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n

17. What are some reasons why you think your child did not like the book? Select all that
apply:
c The story was too long
d
e
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g

c The story was too difficult to understand
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e
f
g
c My child likes other books better
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e
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g

c My child did not like the character, Joey
d
e
f
g

c The story did not keep my child's attention
d
e
f
g
c Other:
d
e
f
g

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.
j Strongly agree
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n
j Agree
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n

j Disagree
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n

j Strongly disagree
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n

19. The information I learned in the book, Amazing Me, has me thinking more about how
my child is growing and developing.
j Strongly agree
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n
j Agree
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n

j Disagree
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n

j Strongly disagree
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n

20. The information in the book, Amazing Me, encouraged me to look for developmental
milestones in my child.
j Strongly agree
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n
j Agree
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n

j Disagree
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n

j Strongly disagree
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n

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.
j Strongly agree
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n
j Agree
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n

j Disagree
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n

j Strongly disagree
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n

22. Please select whether or not you have done the following things after reading Amazing 
Me:
I have used the Developmental Milestones for 3­year­olds checklist at the 

Yes

No

No, but I plan to

j
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n

j
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j
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back of the book to check my child's growth and development.
Since reading the book, I have talked with others about developmental 
milestones.
Since reading the book, I have talked with my child's doctor about my 
child's developmental milestones.
Since reading the book, I have looked for more information about 
developmental milestones.

23. What is your age range?
j 20 or under
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n
j 21­30
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n
j 31­40
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j 41­50
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j 50 plus
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n

24. What is your gender?
j Male
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n

j Female
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n

25. Are you of Hispanic or Latino origin?

j Yes
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n
j No
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n

26. What is your race/ethnicity? Please select all that apply.
j American Indian or Alaska Native
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n
j Asian
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n

j Black or African American
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n

j Native Hawaiian or Other Pacific Islander
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n
j White
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n

j Prefer not to answer
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n

27. What is the highest level of education you have completed?
j Less than high school
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n

j High school diploma or GED
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n

j Technical college/Associates degree
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n
j Some college
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n

j College degree
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n

j Graduate degree
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n

28. Which best describes your total household income?
j Under $15,000
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n

j $15,000­$24,999
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n
j $25,000­$34,999
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j $35,000­$49,999
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j Over $50,000
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n

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?

j Yes
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n
j No
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30. Where does your child USUALLY go when he/she is sick or you need advice about
his/her health?
j Doctor's Office
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n

j Emergency Room
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n
j Urgent Care
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n

j Hospital Outpatient Department
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n

j Clinic (including Public Health Clinic or Vaccine Clinic)
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n
j Some other place:
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n

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