Act Early Parent Intercept Interview Screener Screenshot

Children's Health Project Survey
Pre­Survey Questions

Form Approved 
OMB Number: 0920­xxxx 
Expiration Date: xx/xx/20xx 
Thank you for your interest in the Children’s Health Project. Please answer just a few questions to see if you are eligible to participate in the survey. 
It should take no more than 5 minutes and if you are eligible, you will be able to take the survey immediately. After you finish the survey, you will 
receive a $10 gift card to Target as a token of appreciation for your participation. 

*1. How old are you?
j Less than 18
k
l
m
n
j 18 ­ 55
k
l
m
n

j Greater than 55
k
l
m
n

Public reporting burden of this collection of information is estimated to average 5 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 D­74, Atlanta, Georgia 30333; ATTN: OMB (0920­
XXXX) 

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Children's Health Project Survey

*2. Are you the parent or legal guardian of a child age 5 or younger?

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

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*3. Do you have a child who has been diagnosed with a developmental delay or

developmental disability (e.g., ADHD, Autism, Cerebral Palsy, hearing loss, vision
impairment, speech or language delay, intellectual or learning disability)?

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

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*4. Have you ever worked in the health or medical field (e.g., as a nurse, physician or

medical assistant)?

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

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*5. Do you work in a clinic, hospital, or doctor’s office?

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

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Children's Health Project Survey

*6. Do you work with children who have special needs or in special education?

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

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Children's Health Project Survey

*7. Are you comfortable speaking and reading in English?

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

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Children's Health Project Survey

*8. Have you received the book, Amazing Me. It’s Busy Being 3! from your child’s doctor's

office or any place else?

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

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*9. Have you participated in a focus group in the last few months with other parents for

the Children's Health Project?

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

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Children's Health Project Survey

*10. Which best describes your total household income?
j Less than $15,000
k
l
m
n

j $15,000 to $24,999
k
l
m
n
j $25,000 to $34,999
k
l
m
n
j $35,000 to $50,000
k
l
m
n
j Over $50,000
k
l
m
n

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Children's Health Project Survey

Thank you for answering those questions. You are eligible to participate in the survey. Please click “CONTINUE” to take the survey. 

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Children's Health Project Survey

Thank you for answering those questions. Unfortunately you’re not eligible to participate in the survey, but we appreciate your interest and your 
time today. 

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