Family Resource Dissemination

Family Resource Evaluation
Form Approved, OMB No. 0920-XXXX Exp. Date XX/XX/20XX
This survey is in reference to the material/s you received from the Tourette Syndrome Association. The resources were
developed through a partnership with the U.S. Centers for Disease Control and Prevention. Survey results will allow us to
better understand and address your needs and allow for additional materials to be developed and disseminated. Thank
you for your time.
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 Information Collection Review Office, 1600 Clifton Road NE, MS D- 74, Atlanta,
Georgia 30333; ATTN: PRA (0920-XXXX).

1. Please indicate your relationship to a person with TS.
j
k
l
m
n

Self

j
k
l
m
n

Friend

j
k
l
m
n

Parent

j
k
l
m
n

Teacher

j
k
l
m
n

Other relative

j
k
l
m
n

Service provider

j
k
l
m
n

General interest in TS

Other (please specify):

2. Which resource did you use?
6
Other (please specify):

3. What were your main reasons for using this resource? Check all that apply.
c
d
e
f
g

Newly Diagnosed

c
d
e
f
g

Need updated/specific information

c
d
e
f
g

To help me educate others

c
d
e
f
g

Increase overall knowledge

Other (please specify):

4. How much of the content was new to you?
j
k
l
m
n

Almost all

j
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l
m
n

75%

j
k
l
m
n

50%

j
k
l
m
n

25%

j
k
l
m
n

Almost none

Family Resource Evaluation
5. Please rate your knowledge related to the following areas before and after using this
resource.
Knowledge Before

Knowledge After

Diagnosis/Recognition of TS

6

6

Common conditions that occur with TS

6

6

Medical treatment options

6

6

Behavioral treatment options

6

6

Impact of symptoms on school performance

6

6

Strategies to improve school performance

6

6

6. Please rate the following statements
Strongly

Strongly

Does not

disagree

apply

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Agree

Disagree

j
k
l
m
n

j
k
l
m
n

I feel better able to cope with issues related to my/my child's TS

j
k
l
m
n

I plan to share the information I learned with my/my child's school or

agree
I plan to use the information I learned to help with an individual or
family need or concern

health care provider
I am better prepared to educate others about TS
Comment:

7. Please provide any additional comments or suggestions of topics for TSA website or
DVD programs that could benefit the TSA community
5
6