Act Early Parent Interview- Word

Attachment 10 Act Early Parent Intercept Interview Form Approved

OMB NO. 0920-XXXX

Exp. Date: xx/xx/xxxx

Attachment 10

Act Early Parent Intercept Interview

Introduction and Consent

Thank you for your interest in this study and your willingness to participate. Your privacy is very important to us. Your responses to all questions will be kept secure. You will not be asked to provide any personal identifying information. Only people working on this study will have access to your survey responses. Your participation is completely voluntary, but your participation is important and will help CDC in their efforts to develop educational materials for parents. The survey will take less than 15 minutes and you will receive a $10 gift card to Target as a token of appreciation for your participation once the survey is complete. You may choose to exit the survey at any time.

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

• Yes, I would like to participate in the survey.

• No. I do not want to participate at this time.

Pre-Test Questions

The first few questions are about things you might do if you had a concern about how your child is developing— that is, how your child plays, learns, speaks, acts or moves for his/her age.

2. How confident are you that you would know what to do if you had a concern about your child’s development (how your child plays, learns, speaks, acts or moves for his/her age)?

• Not Confident

• Somewhat Confident

• Very Confident

3. If you had concerns about your child’s development, how LIKELY would you be to do the following?

	Very Unlikely	Somewhat Unlikely	Somewhat Likely	Very Likely
Talk with your child’s doctor about the concern.	1	2	3	4
If you or the doctor is concerned, how likely are you to:
Ask your doctor for a referral to a specialist for further screening.	1	2	3	4
Call your state’s local early intervention program to have your child evaluated for services.	1	2	3	4

5. If you had concerns about your child’s development, how COMFORTABLE would you feel doing the following?

		Very Uncomfortable	Somewhat Uncomfortable	Somewhat Comfortable	Very Comfortable
Talking with your child’s doctor about the concern.		1	2	3	4
If you or the doctor is concerned, how comfortable would you feel:
Asking your doctor for a referral to a specialist for further screening.	1		2	3	4
Calling your state’s local early intervention program to have your child evaluated for services.	1		2	3	4

6. Which of the following are reasons you might not talk to a doctor or you might wait to talk to a doctor, if you had concerns about how your child is developing? Choose all that apply.

1. Fear or nervousness about talking to a doctor

2. Feeling rushed, like there’s no time to raise these concerns

3. Doctor is not helpful

4. Doctor would tell me if there was a problem

5. Doctor is usually too busy

6. Being a first-time parent

7. Worried about receiving bad news

8. Waiting to see if things get better (child “catches up” or “outgrows” the problem)

9. Doctor hasn’t taken my concerns seriously

10. Doctors have previously dismissed my concerns about my child’s development

11. Doctors are not the right people to talk to about my child’s development

12. None of these responses apply to me - I would always talk to my doctor about my concerns

13. Something else/other reason

Please Specify: _____________

Please take a few minutes to look through and read the [brochure/booklet].

[PROGRAMMING NOTE: INSERT A STOP SCREEN HERE AND INSTRUCT RESPONDENT TO WAIT FOR FURTHER DIRECTION FROM INERVIEWER.

INTERVIEWER WILL GIVE RESPOMNDENT HARD COPY OF THE MATERIAL THEY ARE REVIEWING AND ASK THEM TO READ THROUGH IT BEFORE PROCEEDING WITH THE SURVEY.]

Now you will be asked some questions about the [brochure/booklet] specifically.

Post-Test Questions

7. Did you notice [the message about acting early (also pictured to the right) on the inside flap of the brochure/a message about acting early (similar to the one pictured below) on the bottom of many pages throughout the booklet] you just reviewed?

   1. Yes

   2. No

8. Thinking about the message about acting early you read in the [brochure/booklet], please indicate how much you agree or disagree with the following statements.

[RANDOMIZE]

	Strongly Disagree	Disagree	Agree	Strongly Agree
I didn’t understand some of the message.	1	2	3	4
There is something I didn’t like about the message.	1	2	3	4
The information in the message is helpful.	1	2	3	4
The message encouraged me to take action if I ever had a concern about my child’s development.	1	2	3	4
After reading the message, I feel confident that I know what to do if I ever have a concern about my child’s development.	1	2	3	4
I did not learn anything new from this message.	1	2	3	4

10. After reviewing this [brochure/booklet], how LIKELY are you to do the following?

	More likely	Less likely	No change from before
Talk to my child’s doctor, if I had a concern my child’s development.	1	2	3
After reviewing this [brochure/booklet], if you or the doctor is concerned, how likely are you to:
Ask the doctor for a referral to a specialist for further screening.	1	2	3
Call your state’s local early intervention program to have your child evaluated for services.	1	2	3

11. After reviewing this [brochure/booklet], how COMFORTABLE are you doing the following?

	More comfortable	Less comfortable	No change from before
Talking to my child’s doctor, if I had a concern about my child’s development.	1	2	3
After reviewing this [brochure/booklet], if you or the doctor is concerned, how comfortable would you feel:
Asking your doctor for a referral to a specialist for further screening.	1	2	3
Calling your state’s local early intervention program to have your child evaluated for services.	1	2	3

11. Does the [brochure/booklet] encourage parents to:

Talk to their doctor right away about their concerns and not wait	No	Yes
Look for their child’s milestones.	No	Yes
Take action if they have a concern.	No	Yes

11. After reading the [brochure/booklet], which of the following best describes you?

• The [brochure/booklet] made me less likely to act early, if I had a concern about my child’s development.

• The [brochure/booklet] made me more likely to act early, if I had a concern about my child’s development.

• The [brochure/booklet] had no effect on how I would act early, if I had a concern about my child’s development.

Demographic Questions

11. What is your age range?

• 20 or under

• 21-30

• 31-40

• 41-50

• 50+

11. How many children do you have?

__________________________

11. What is the age of your youngest child (in years)?

__________________________

11. What is the highest level of education you have completed?

• Less than high school

• High school diploma or GED

• Technical college/Associates degree

• Some college

• College degree

• Graduate degree

11. Are you of Hispanic or Latino origin?

• Yes

• No

11. How would you describe your race? (Select all that apply.)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

• Decline to answer

Thank you for your time!

Public reporting burden of this collection of information is estimated to average 15 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)