Parent Survey - HEADS UP_Rocket Blades

Form Approved

OMB No. 0920-1009

Exp. Date: 3/31/2017

Public Reporting burden of this collection of information is estimated at 60 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 NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-1009).

HEADS UP Parent Survey

1. Has your child ever been diagnosed with a concussion? [Yes, No]

2. Has anyone close to your child ever been diagnosed with a concussion (e.g., sibling, close relative, close friend)? [Yes, No]

3. How frequently do you watch football on television? [never, yearly, monthly, weekly, daily]

4. How frequently does your child watch football on television? [never, yearly, monthly, weekly, daily]

5. Have you ever talked about concussions with your child? [Yes, No]

6. How worried are you about concussions? [not at all worried, somewhat worried, very worried]

7. Please describe WHY you are worried or not worried about concussions from sport? [Open-ended]

8. Do you think your child learned something new about concussion and concussion prevention after playing the game? [yes, no, not sure]

9. Did you learn something new about concussion and concussion prevention in young children after watching your child play the game? [yes, no, not sure]

   1. If yes, what did you learn? [Open-ended]

10. A child is experiencing the signs and symptoms listed below after a bump, blow, or jolt to the head or body. Are the following symptoms sufficient reasons to keep them out of play until a doctor or medical professional has evaluated them? [1=yes, 2=no, 3= I don’t know]?

1. Headaches or “pressure” in head

2. Nausea or vomiting

3. Double or blurry vision

4. Sensitivity to light

5. Sensitivity to noise

6. Numbness in hands and toes

7. Feeling sluggish, hazy, foggy, or groggy

8. Confusion

9. Balance problems or dizziness

10. Slurred speech

11. Seizures

12. Cannot recognize people or places

11. If your child was on an organized sports team and the coaching staff wanted the children and parents to understand basic concussion prevention, would you prefer for them to give you a fact sheet (show an example fact sheet), encourage you to download Rocket Blades so your child could play it and talk to you about it, or to share concussion information with you and your child in another way other than a fact sheet or the game? [Fact sheet, Rocket Blades, Other]

    1. If other, please describe your preferred option [Open-ended]

12. How often do you download educational gaming apps for your child? [never, rarely, occasionally, frequently]

13. How likely would you be to download a health education game like Rocket Blades for your child? [not likely, somewhat likely, very likely]

    1. Please explain the reason for your answer [Open-ended]

14. Where or from whom do you think parents would expect to receive information about a game like Rocket Blades? [Open-ended]