Learn the Signs. Act Early Bulk Orders

Form Approved

OMB # 0920-0919

Exp.: 1/13/2018

Survey for LTSAE Bulk Order Requesters
Survey for LTSAE Materials Customization Requesters

[Customer Satisfaction Survey Items]

1. Did you place a bulk order (a large order that required a special request) for any Learn the Signs. Act Early. materials, like the examples below?

1. Yes

2. No [end survey]

1. For which material(s) did you place a bulk order?

	English	Spanish
Brochure [image]
Milestones Moments Booklet [image]
Amazing Me!/Soy Maravilloso [image]
Flyer [image]
Growth Chart [image]
Materials Disk [image]
Parent Kit [image]
Other (please specify:________)

3. How did you find out about LTSAE materials (select that apply)?

	Yes	No
Conference exhibit (please describe, if applicable: _______________________)
Conference session (please describe, if applicable: _______________________)
Webinar (please describe, if applicable: _______________________)
Email (please describe, if applicable: _______________________)
Colleague (please describe, if applicable: _______________________)
Act Early Ambassador (please describe, if applicable: _______________________)

4. How did you find out that these materials could be ordered in bulk? [open-ended]

5. How difficult or easy was it to order LTSAE materials in bulk?

   1. Very difficult

   2. Somewhat difficult

   3. Somewhat easy

   4. Very easy

6. We’re sorry it was difficult to order LTSAE materials in bulk. May we contact you to learn more about the challenges and to offer assistance if needed?

   1. No

   2. Yes (email address: ______________________)

7. In which of the following ways were the materials used (select all that apply)?

   1. Distributed at Health fairs or community events

   2. Given directly to parents of young children

   3. Distributed to early care and education providers

   4. Distributed to healthcare providers

   5. Used for teaching High School or post-secondary (e.g. given to students for a course on early child development)

   6. Not yet used.

   7. Used for trainings (who was the training audience? __________________________)

8. Did you use the materials in any way other than described above? [open-ended]

9. Did you get the number of materials that you initially requested?

   1. Yes

   2. I don’t remember

   3. No (why not?________________________)

10. Did you distribute all of the materials?

    1. Yes

    2. No, but I think I will

    3. No, and I don’t think I will (why not?____________)

11. How useful, if at all, were the LTSAE materials that you ordered?

    1. Not at all useful

    2. Somewhat useful

    3. Very useful

12. Do you plan to order more LTSAE materials in bulk (select all that apply)?

    1. Yes, the same item(s)

    2. Yes, different items(s)

    3. No (why not?________________)

13. Why did you choose to order these materials instead of printing them?

    1. Don’t have the ability to print

    2. Don’t have the funds to print the quantities I need

    3. Did not know that was an option

14. Is there anything else you’d like to tell us? [open-ended]

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

[Demographic survey items]

We'd like to know a little bit more about you and your organization. This information is completely optional

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. What population(s) does your organization directly serve? (Select all that apply)

   1. Parents of young children

   2. Childcare/Early Education professionals

   3. Healthcare professionals

   4. Family service professionals

   5. Parents of children with disabilities

   6. Other (please specify:___________________)

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)

   1. Immigrants

   2. Refugees

   3. Low-income

   4. Middle-income

   5. High-income

   6. Rural

   7. Urban

   8. Suburban

   9. Mostly English Speakers

   10. Mostly Spanish Speakers

   11. Mostly Speakers of Other Languages

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).