2 Substudy AlabamaOutreach PrePostAssessment

OMB # 0925-0701

Expiration Date: 07/31/2017

Safe Sleep Outreach
Project Assessment Form

Public reporting burden for this collection of information is estimated to average 3 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0701). Do not return the completed form to this address.

Participation is voluntary and you may choose to discontinue or have your responses withdrawn at any time.

Please fully complete this form, and return it to your presenter. Your feedback is very important. Thank you. Do NOT write your name on this form.

NOTE: Please be advised that the Safe Sleep Outreach Project and the data collection is sponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The purpose of collecting the information required on this form is to help NICHD assess prior knowledge before the program and attendees’ understanding after programs. All personal information will be stored in a locked cabinet.

Host organization:

Event Date:

Activity type:

BEFORE This Program	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1) In my home, the place where baby sleeps has soft bedding (example: pillows, blankets, toys, bumpers, or other soft items).	1	2	3	4	5
2) I know that the safest place for baby to sleep is in the same room as the caregiver but in his or her own crib or bassinet.	1	2	3	4	5
3) Putting baby on his or her back to sleep is important to reduce the risk of SIDS.	1	2	3	4	5

Please complete the sections below AFTER the program

AFTER This Program	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1) In my home, the place where baby sleeps has soft bedding (example: pillows, blankets, toys, bumpers, or other soft items).	1	2	3	4	5
2) I know that the safest place for baby to sleep is in the same room as the caregiver but in his or her own crib or bassinet.	1	2	3	4	5
3) Putting baby on his or her back to sleep is important to reduce the risk of SIDS.	1	2	3	4	5

Program Assessment	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1) Presenter demonstrated expert knowledge on safe sleep.	1	2	3	4	5
2) After completing this program, I know ways to reduce the risk of SIDS and other sleep-related causes of infant death.	1	2	3	4	5
3) This program was sensitive to my cultural beliefs and practices.	1	2	3	4	5
4) I would share this information with friends, family and other caregivers who take care of babies.	1	2	3	4	5

I would like more information about: