2 Alabama Outreach Assessment Form

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.

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.
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).

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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.

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3) Putting baby on his or her back to
sleep is important to reduce the risk of
SIDS.

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Please complete the sections below AFTER the program
AFTER This Program
1) In my home, the place where baby
sleeps has soft bedding (example:
pillows, blankets, toys, bumpers, or
other soft items).
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.
3) Putting baby on his or her back to
sleep is important to reduce the risk of
SIDS.
Program Assessment
1) Presenter demonstrated expert
knowledge on safe sleep.
2) After completing this program, I
know ways to reduce the risk of SIDS
and other sleep-related causes of
infant death.
3) This program taught me safe infant
sleep habits that I can use in my home
with my family.
4) I would share this information with
friends, family, and other caregivers
who take care of babies.

I would like more information about:

Strongly
Disagree

Disagree Neutral

Agree

Strongly
Agree

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Agree

Strongly
Agree

Strongly
Disagree

Disagree Neutral

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