Caregiver Rating Worksheet

Form Approved

OMB# 0920-0572

Exp. 03/31/2018

Attachment 4_Focus Group Rating Worksheet_Caregiver

ID: _____________ GROUP: ______________

1. What do you think about this message? Please give it a

grade from A to F. (check only one response)

A

B

C

D

F

2. How much do you agree or disagree with the following

statements. (check only one response for each item)

	Strongly Disagree	Disagree	Neither Agree Nor Disagree	Agree	Strongly Agree
This message would make my child want to take steps to manage his/her asthma
This message makes me want more information about managing asthma

Public reporting burden of this collection of information is estimated to average 15 minutes per worksheet, 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: PRA (0920-0572)