Learn the Signs. Act Early. Customization of Materials Customer Feedback Survey

Form Approved

OMB No. 0920-0919

Exp. Date: 01/31/2018

Survey for LTSAE Materials Customization Requesters

[Customer Satisfaction Survey Items]

1. Did you request to customize Learn the Signs. Act Early. materials, like the examples below?

1. Yes

2. No [end survey]

1. Have you customized these materials?

   1. Yes

   2. Not yet, but I plan to [end survey]

   3. No, and I don’t plan to. If no, why not? __________________ [end survey]

2. Which materials did you (or do you plan to) customize?

   1. Brochure [image]

   2. Booklet [image]

   3. Checklist [image]

   4. Game Board Poster [image]

   5. Amazing Me! [image]

   6. Other: ____________________

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: _______________________)
Web search (please describe, if applicable: _______________________)
Newsletter (please describe, if applicable: _______________________)
Watch Me! Training (please describe, if applicable: _______________________)
Autism Case Training (please describe, if applicable: _______________________)
Other training (please describe, if applicable: _______________________)
Other (please describe, if applicable: _______________________)

5. How did you find out that these materials were available for customization? [open-ended]

6. In which of the following ways did you to customize the materials (select all that apply)?

   1. Add your organization’s logo

   2. Add local contact information

   3. Change or add images

   4. Add content

   5. Revise content

   6. Delete content

   7. Take content to create new product/material (please describe): _____________________________

7. If you added, changed, or revised images and/or content, please describe these changes below: [open-ended]

8. Did you customize the material(s) in any other ways than listed above?

   1. No

   2. Yes (please describe: ________________)

9. Were there any customizations you were unable to make?

   1. No

   2. Yes (What was it and why couldn’t you do it?: _________________________)

10. How difficult or easy was it to customize LTSAE materials?

    1. Very difficult

    2. Somewhat difficult

    3. Somewhat easy [skip Q11]

    4. Very easy [skip Q11]

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

    1. No

    2. Yes (email address: ______________________)

12. In which of the following ways were the customized 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? __________________________)

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

14. Have you ordered or printed these or other LTSAE materials without customizing them?

    1. Yes

    2. No

    3. I don’t remember

15. What did you do to make your customized materials available to your target audience? (Select all that apply)

    1. Printed them

    2. Sent in email(s) [skip Q16-18]

    3. Put online [skip Q16-18]

    4. None [skip Q16-18]

    5. Other (please specify: ____________________) [skip Q16-18]

16. About how many total copies did you print of all customized materials? [open-ended]

17. Were you able to print enough materials to serve your needs?

    1. Yes

    2. No ( why not? __________________________)

18. Do you plan to continue printing the customized materials?

    1. Yes, all of them

    2. Yes, some of them

    3. No (why not?: ___________________________)

19. Do you plan on customizing different LTSAE materials?

    1. Yes (which?____________________

    2. No

    3. Maybe

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

21. 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).