Follow-up Survey

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

Amazing Me - Parent Contact Information Survey
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?

j Yes
k
l
m
n
j No
k
l
m
n

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)

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Amazing Me - Parent Contact Information Survey
3. To receive your $5 online Target or Wal­Mart 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.)
EMAIL:
EMAIL AGAIN:

4. To receive your $5 gift card in the mail, please share your mailing information.
NAME:
STREET:
CITY:
STATE:
ZIP:

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Amazing Me - Parent Contact Information Survey
5. Would you like to earn $40 by participating in a group discussion with parents like you
in your community (name, phone number, and/or email address required)?

j Yes
k
l
m
n
j No
k
l
m
n

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Amazing Me - Parent Contact Information Survey
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:

7. Please enter your email address below:
EMAIL:
EMAIL AGAIN:

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Amazing Me - Parent Contact Information Survey
Thank you. If you'd like more information about Amazing Me, please visit: 
http://www.cdc.gov/ncbddd/actearly/amazingme.html 

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