Screening/Demographics

Attachment I1:
Screening and Demographics
Questionnaires
Research on the Efficacy and Feasibility of
Essentials for Parenting Toddlers and Preschoolers
Division of Violence Prevention
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention

Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/20xx
Public reporting burden of this collection of information is estimated to average 15 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 Information Collection Review
Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Screening and Demographics Questionnaires
(S) indicates to be asked in screener

QUESTIONS ABOUT YOU
How old are you?
years [dropdown]
How do you describe your gender?
□ Male
□ Female
□ Other (please describe): .................................................................
Please answer both of the following questions about Hispanic origin and race. For the
purposes of this survey, we do not consider Hispanic origin to be a race.
Are you of Hispanic, Latino or Spanish origin?
 Yes
 No
What is your race? You can choose more than one category.
 American Indian or Alaska Native
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
What is your household income per year, before taxes? Please include any income from you,
your family members who live with you, and any other people who live with you and share
living expenses with you
How many people live in your household? By household we mean people who live together and
share living expenses. Please include yourself in this count.
[dropdown]

Are you comfortable answering questions in English for online surveys?
Yes
No

Attachment I1

ABOUT YOUR CHILDREN
How many children do you parent? Please count only children who live with you.
_______ [dropdown]
Please list the age in years of the children you parent who live with you:
[If possible display the number of lines for number of children parented]
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

Age in years (dropdown: less than 1, 1, 2, 3, 4,
more than 4)
Age in years (dropdown: less than 1, 1, 2, 3, 4,
more than 4)
Age in years (dropdown: less than 1, 1, 2, 3, 4,
more than 4)
Age in years (dropdown: less than 1, 1, 2, 3, 4,
more than 4)
Age in years (dropdown: less than 1, 1, 2, 3, 4,
more than 4)
Age in years (dropdown: less than 1, 1, 2, 3, 4,
more than 4)

Please answer a few questions about your child who is at least 2 years old but younger than
5 years old. If you have more than one child in that age range, please answer about the
oldest child. This will be the child we’ll ask you to focus on for study activities.
What is this child’s gender?
 Male
 Female
What is this child’s age? Please answer in both years and months. [dropdowns]
_______ Years
________Months
What is this child’s relation to you?
 Biological child
 Adopted child
 Step child
Submit button

Attachment I1

(if eligible)
CONGRATULATIONS!
You are qualified to participate in our study, and are eligible to receive $250 for your active
participation. Pleas enter your name, email and phone number below so that we may contact you
with more information.
Name:
Email:
Phone number:

Submit button

(if not eligible)
We’re sorry, you are not eligible.
Thank you for your time and interest in this study.

Attachment I1