3 Kappa Before After Activity Knowledge Check

OMB # 0925-0701

Expiration Date: 02/2021

Kappa Safe Infant Sleep Community Engagement Project

Before-and-After Activity Knowledge Check

Public reporting burden for this collection of information is estimated to average 3 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0701). Do not return the completed form to this address.

Please answer the questions on this form and return it to your presenter after the outreach activity is complete. Do not write your name on this form. Thank you for your feedback!

Host Chapter

Activity/event date:

Activity/event name:

Pre-Test: Please complete this section before the program begins.

Instructions: Check either True or False for each statement below.

Statement	True	False
Sudden Infant Death Syndrome, or SIDS, is the leading cause of death among babies between 1 month and 1 year of age.	☐	☐
Babies should always be placed on their backs to sleep until they are 1 year old.	☐	☐
It is safe to have pillows, blankets, crib bumpers, or soft items in the area immediately around where the baby sleeps.	☐	☐
The safest place for baby to sleep is in the same room as the caregiver but in baby’s own crib or bassinet.	☐	☐
When a baby sleeps on a bed, couch, or armchair with a caregiver or others, the risk of SIDS and other sleep-related causes of infant death (ex: suffocation, strangulation) is higher than when the baby sleeps in a crib or bassinet.	☐	☐

Wait! Don’t turn the page over until after the program is finished.

Post-Test: Please complete this section after the program is finished.

Instructions: Check either True or False for each statement below.

Statement	True	False
Sudden Infant Death Syndrome, or SIDS, is the leading cause of death among babies between 1 month and 1 year of age.	☐	☐
Babies should always be placed on their backs to sleep until they are 1 year old.	☐	☐
It is safe to have pillows, blankets, crib bumpers, or soft items in the area immediately around where the baby sleeps.	☐	☐
The safest place for baby to sleep is in the same room as the caregiver but in baby’s own crib or bassinet.	☐	☐
When a baby sleeps on a bed, couch, or armchair with a caregiver or others, the risk of SIDS and other sleep-related causes of infant death (ex: suffocation, strangulation) is higher than when the baby sleeps in a crib or bassinet.	☐	☐

Instructions: Check one response for each statement below.

Statement	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I learned helpful information from this activity/event.	☐	☐	☐	☐	☐
The information presented was clear and understandable.	☐	☐	☐	☐	☐
The presenter was knowledgeable about the topics discussed at this activity/event.	☐	☐	☐	☐	☐
I would share this information with friends, family, and others who take care of babies.	☐	☐	☐	☐	☐
In the future, I will always put my baby to sleep on his or her back, for naps and at night.	☐	☐	☐	☐	☐
In the future, I will create a safe sleep environment for my baby using the recommendations I learned in today’s activity/event.	☐	☐	☐	☐	☐

How could we improve this activity/event?

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