Interview Screener - Word

Attachment 9 Act Early Parent Intercept Interview Screener Form Approved

OMB NO. 0920-XXXX

Exp. Date: xx/xx/xxxx

Attachment 9

Act Early Parent Intercept Interview Screener

Thank you for your interest in the Children’s Health Project. Please answer just a few questions to see if you are eligible to participate in the survey. It should take no more than 5 minutes and if you are eligible, you will be able to take the survey immediately. After you finish the survey, you will receive a $10 gift card to Target as a token of appreciation for your participation.

1. How old are you?

• IF 18-55→ CONTINUE

• IF <18 or >55 →THANK AND END [INELIGIBLE]

2. Are you the parent or legal guardian of a child age 5 or younger?

• IF YES → CONTINUE

• IF NO →THANK AND END [INELIGIBLE]

3. Do you have a child who has been diagnosed with a developmental delay or developmental disability (e.g., ADHD, Autism, Cerebral Palsy, hearing loss, vision impairment, speech or language delay, intellectual or learning disability)?

• IF YES → THANK AND END [INELIGIBLE]

• IF NO → CONTINUE

4. Have you ever worked in the health or medical field (e.g., as a nurse, physician or medical assistant)?

• IF YES → - THANK AND END [INELIGIBLE]

• IF NO → CONTINUE

5. Do you work in a clinic, hospital, or doctor’s office?

• IF YES → THANK AND END [INELIGIBLE]

• IF NO → CONTINUE

6. Do you work with children who have special needs or in special education?

• IF YES → THANK AND END [INELIGIBLE]

• IF NO → CONTINUE

7. Are you comfortable speaking and reading in English?

• Yes → CONTINUE

• No → THANK AND END [INELIGIBLE]

8. Have you received the book, Amazing Me. It’s Busy Being 3! from your child’s doctor’s office or any place else?

• Yes → CONTINUE

• No → THANK AND END [INELIGIBLE]

9. Have you participated in a focus group in the last few months with other parents for the Children’s Health Project?

• IF YES → THANK AND END [INELIGIBLE]

• IF NO → CONTINUE

10. Which best describes your total household income?

• Less than $15,000

• $15,000 to $24,999

• $25,000 to $34,999

• $35,000 to $50,000

• Over $50,000→ THANK AND END [INELIGIBLE]

[ELIGIBLE RESPONDENTS:] Thank you for answering those questions. You are eligible to participate in the survey. Please click “CONTINUE” at the bottom of your screen to take the survey.

[INELIGIBLE RESPONDENT TERMINATION:] Thank you for answering those questions. Unfortunately you’re not eligible to participate in the survey, but we appreciate your interest and your time today.

Public reporting burden of this collection of information is estimated to average 5 minutes, 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 NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  OMB (0920-XXXX)

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