Download:
pdf |
pdfForm Approved
OMB Number: 0920xxxx
Expiration Date: xx/xx/20xx
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 the Centers for Disease Control and
Prevention (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.
*10. I have read and understand this information and agree to participate:
j Yes, I would like to participate in the survey.
k
l
m
n
j No. I do not want to participate at this time.
k
l
m
n
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 D74, Atlanta, Georgia 30333; ATTN: OMB (0920
XXXX)
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.
11. 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)?
j Not Confident
k
l
m
n
j Somewhat Confident
k
l
m
n
j Very Confident
k
l
m
n
12. 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
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Talk with your child's doctor about the
concern.
13. If you or the doctor is concerned, how likely are you to:
Very Unlikely
Somewhat Unlikely
Somewhat Likely
Very Likely
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Ask your doctor for a referral to a specialist
for further screening.
Call your state’s local early intervention
program to have your child evaluated for
services.
14. 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
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Talking with your child's
doctor about the concern.
15. If you or the doctor is concerned, how comfortable would you feel:
Very Uncomfortable
Asking your doctor for a referral to a
Somewhat
Uncomfortable
Somewhat Comfortable
Very Comfortable
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
specialist for further screening.
Calling your state’s local early intervention
program to have your child evaluated for
services.
16. 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.
c I would talk with a doctor about my concerns
d
e
f
g
c Fear or nervousness about talking to a doctor
d
e
f
g
c Feeling rushed, like there’s no time to raise these concerns
d
e
f
g
c Doctor is not helpful
d
e
f
g
c Doctor would tell me if there was a problem
d
e
f
g
c Doctor is usually too busy
d
e
f
g
c Being a firsttime parent
d
e
f
g
c Worried about receiving bad news
d
e
f
g
c Waiting to see if things get better (child “catches up” or “outgrows” the problem)
d
e
f
g
c Doctor hasn’t taken my concerns seriously
d
e
f
g
c Doctors have previously dismissed my concerns about my child’s development
d
e
f
g
c Doctors are not the right people to talk to about my child’s development
d
e
f
g
c None of these responses apply to me I would always talk to my doctor about my concerns
d
e
f
g
c Something else/other reason (Please Specify)
d
e
f
g
5
6
Let the interviewer know that you've reached
this screen. Do not press "Continue" until
you've received instructions from the
interviewer.
Now you will be asked some questions about the brochure specifically.
17. Did you notice the message about acting early (also pictured to the right) on the inside
flap of the brochure you just reviewed?
j Yes
k
l
m
n
j No
k
l
m
n
18. Thinking about the message about acting early you read in the brochure, please
indicate how much you agree or disagree with the following statements.
Strongly Disagree
Disagree
Agree
Strongly Agree
There is something I didn’t like about the message.
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
The message encouraged me to take action if I ever had a concern about
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
I didn’t understand some of the message.
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
After reading the message, I feel confident that I know what to do if I ever
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
The information in the message is helpful.
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
I did not learn anything new from this message.
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
my child’s development.
have a concern about my child’s development.
19. After reviewing this brochure, how LIKELY are you to do the following?
Talk to my child’s doctor, if I had a concern about my
More likely
Less likely
No change from before
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
child’s development.
20. After reviewing this brochure, if you or the doctor is concerned, how likely are you to:
Ask the doctor for a referral to a specialist for further
More likely
Less likely
No change from before
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
screening.
Call your state’s local early intervention program to have
your child evaluated for services.
21. After reviewing this brochure, how COMFORTABLE are you doing the following?
Talking to my child’s doctor, if I had a concern about my
More comfortable
Less comfortable
No change from before
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
child’s development.
22. After reviewing this brochure, if you or the doctor is concerned, how comfortable
would you feel:
Asking your doctor for a referral to a specialist for further
More comfortable
Less comfortable
No change from before
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
screening.
Calling your state’s local early intervention program to
have your child evaluated for services.
23. Does the brochure encourage parents to:
No
Yes
Talk to their doctor right away about their concerns and not wait.
j
k
l
m
n
j
k
l
m
n
Look for their child’s milestones.
j
k
l
m
n
j
k
l
m
n
Take action if they have a concern.
j
k
l
m
n
j
k
l
m
n
24. After reading the brochure, which of the following best describes you?
j The brochure made me less likely to act early, if I had a concern about my child’s development.
k
l
m
n
j The brochure made me more likely to act early, if I had a concern about my child’s development.
k
l
m
n
j The brochure had no effect on how I would act early, if I had a concern about my child’s development.
k
l
m
n
25. What is your age range?
j 20 or under
k
l
m
n
j 2130
k
l
m
n
j 3140
k
l
m
n
j 4150
k
l
m
n
j 50+
k
l
m
n
26. How many children do you have?
27. What is the age of your youngest child (in years)?
28. What is the highest level of education you have completed?
j Less than high school
k
l
m
n
j High school diploma or GED
k
l
m
n
j Technical college/Associates degree
k
l
m
n
j Some college
k
l
m
n
j College degree
k
l
m
n
j Graduate degree
k
l
m
n
29. Are you of Hispanic or Latino origin?
j Yes
k
l
m
n
j No
k
l
m
n
30. How would you describe your race? (Select all that apply.)
c American Indian or Alaska Native
d
e
f
g
c Asian
d
e
f
g
c Black or African American
d
e
f
g
c Native Hawaiian or Other Pacific Islander
d
e
f
g
c White
d
e
f
g
c Decline to answer
d
e
f
g
| File Type | application/pdf |
| File Modified | 2014-04-30 |
| File Created | 2014-04-30 |