(Completed by adult guardian)
Date: ______________________
Thank you for your interest in our study. First, I would like to tell you a little bit about the study and if you are still interested, I will need to get some information from you.
Westat is conducting the study for the Consumer Product Safety Commission (CPSC) and we are looking for children between the ages of 2- through 4-years-old. The study is being conducted to gather information that will help the CPSC determine the developmentally appropriate ages for selected toys. To do this, your child will be asked to play with nine different toys. We will also be asking you to look at the toys and fill out a questionnaire. The study will take place over two sessions. The first session will take about 75 minutes and the second session will be 60 minutes, both will take place at Westat in Rockville, MD.
During the study, information will be gathered from observational data of your child’s interactions with ten toys from six toy categories (smart toys, take-apart vehicles, musical instruments, figurines, plush toys with electronic components, and manipulatives). You will be asked to be present at all times. We will be videotaping your child playing with the toys to help with our analysis and writing a report of our findings. Additionally, you will be given the opportunity to look at the toys. You will be able to interact with the toy and you will be asked to complete a self-administered questionnaire that asks about your opinion with respect to various topics, such as buying habits, safety, etc. Your will be paid $150 when you and your child complete the study.
We will not be scheduling you for a session today. If your child is eligible, we will add his/her name to the list of potential participants.
NOTE: If parent/guardian has multiple children, complete a screener for each child. Keep screener forms together.
If you are interested, I will need to ask you a few questions to determine if your child is eligible. Are you interested in participating?
a. Yes (If yes, proceed).
b. No (If no, thank the person for their time and end the screener).
What is your Full Name? _________________________
How many children do you have between the ages of 2- through 4-years-old?
If more than one child, explain to the caregiver that:
A separate screener form must be completed for each child.
There is a possibility that only one child may be selected to participate in the study.
If more than one child is selected to participate, the caregiver will need to come in on two separate occasions to participate.
What is your Child’s Full Name? _________________________
How old is your child? _________________________ (If child is < 2 or > 4, thank the person for their time and end the screener).
What is your child’s date of birth? _________________________
What is your child’s gender / How does your child identify?
a. Male OR b. Female OR c. Non-binary
Is your child of Hispanic or Latino origin?
a. Yes b. No
What is your child’s race/ethnicity? Please indicate all that apply to your child:
[Circle all that apply]
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White/Caucasian
Other (Specify) ___________________
Has _____ [insert child’s name] been diagnosed by a medical professional with any of the following conditions? [Circle all that apply]
Attention Deficit Hyperactivity Disorder (ADHD)
Developmental Delays, Disabilities, or Disorders (e.g. Autism, Downs Syndrome, Cerebral Palsy)
(Specify)___________________
Hearing Loss
Vision Loss
In your opinion, do you think _____ [insert child’s name] displays separation anxiety? Separation anxiety is defined as extreme negative reaction such as crying and throwing tantrums, when parent is not around.
Yes
No
Has _____ [insert child’s name] ever engaged in destructive behaviors at home, for example intentionally breaking toys or household objects?
Yes
No
In the past year, how often do you purchase toys for _______ [insert child’s name]?
a. More than 2 times a month
b. Once a month
c. Every 3 or 4 months
d. Only on birthdays or holidays (two times per year)
Where do most typically purchase toys for _______ [insert child’s name]? [Circle all that apply]
In-person at “big-box” stores, like Target, Walmart, Kmart, or Kohl’s
In-person at a boutique toy store
At a second-hand store or yard sale
Online
What if your total household income?
Less than $50,000
$50,000 - $100,000
$101,000 - $150,000
$151,000 - $200,000
Greater than $200,000
What is your highest level of education completed?
Did Not Complete High School
High School/GED
Bachelor's Degree
Master's Degree
Advanced Graduate work or Ph.D.
Can you tell me a phone number where we can easily contact you?
Home: ______________________________________________________
Cell: ________________________________________________________
Email Address:
______________________________________________________________
Home Address (including City and State):
____________________________________________________________________
How did you hear about the study?
Newspaper
Friend
Craig’s List
Flyer
Other ___________________________
Can you tell me which days of the week and times you and your child might be available, if your child is selected to participate?
__________________________________________________________________
__________________________________________________________________
Closing:
Thank you for your time and interest. Once we get a pool of names together, we will schedule the sessions. We cannot guarantee that your child will be included in the study, but we will make every effort to include your child.
If you have any questions, you can reach us at ____________ (provide the phone number of the person who is screening). In addition, if you know anyone else who might be interested in participating, please pass on the contact information to him/her.
Hang up phone.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | amanda.kelley |
| File Modified | 0000-00-00 |
| File Created | 2024-07-20 |