Iniital survey

Attachment 1 Form Approved

OMB No. 0920-0919

Exp. Date 01/31/2015

Initial Survey for LTSAE Webinar Participants

[Demographic survey items]

1. Name of organization or agency where you work

   1. [open-ended]

2. In which state or territory are you located?

   1. [open-ended]

3. Current role or job title:

   1. [open-ended]

4. In your current position, do you have direct contact with parents of children under the age of 5?

   1. Yes, frequently

   2. Yes, but infrequently

   3. No, not at all

5. Which best describes the primary ethnicity or ethnicities of the populations that your organization serves? (check all that apply)

   1. Hispanic or Latino

   2. Not Hispanic or Latino

6. Which best describes the primary race(s) of the populations that your organization serves? (check all that apply)

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African American

   4. Native Hawaiian or Other Pacific Islander

   5. White

7. Which best describes the other primary demographics of the populations that your organization serves? (check all that apply)

Immigrants	High-income	Mostly English Speakers
Refugees	Urban	Mostly Spanish Speakers
Low-Income	Suburban	Mostly Speakers of Other Languages
Middle-Income	Rural

[Customer Satisfaction Survey Items]

8. How much do you agree with the following statements:

	Disagree	Somewhat Disagree	Somewhat Agree	Agree
The webinar sparked my interest in learning more about developmental monitoring.
The webinar increased my understanding of developmental monitoring.
I already knew about CDC's "Learn the Signs. Act Early." materials.
I already use CDC's "Learn the Signs. Act Early." materials.

9. As a result of this training, I plan to:

   1. visit the CDC's "Learn the Signs. Act Early." website presented in the webinar

   2. use at least one of the CDC's "Learn the Signs. Act Early." materials presented in the webinar in my work

10. As a result of this training, I plan to share CDC LTSAE resources with (check all that apply):

    1. Colleagues

    2. Parents

    3. Teachers

    4. No One

    5. Other (please specify)

       1. [open-ended]

11. If you would like help in using CDC LTSAE materials please enter your email address:

The public reporting burden of this collection of information is estimated to average 2 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 - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0919).