Form 1 survey

HEALTHY NATIVE BABIES - OMB Number: 0925-0532/Expiration Date:
1. 1-Day Training Post Survey
Confidentiality Statement: Your information will be kept secure to the extent permitted by law.

1. Type of work you are employed in?
c
d
e
f
g

Clinician

c
d
e
f
g

Community Health Worker

c
d
e
f
g

Medical Assistant

c
d
e
f
g

Nurse

c
d
e
f
g

Prenatal Care Coordinator

c
d
e
f
g

Prevention Coordinator

c
d
e
f
g

Social Worker

Other (please specify)

2. The Healthy Native Babies Project is interested in learning about any health education
you have conducted or information you have shared regarding SIDS risk-reduction
since attending the Healthy Native Babies 1-day training in 2009. Please tell us if you
have been able to do any of the activities listed below. (Check all that apply)
c
d
e
f
g

Provided information/health education to an individual/family in a clinic

c
d
e
f
g

Provided information/health education to an individual/family in their home

c
d
e
f
g

Provided information/health education at a health fair or community event/gathering

c
d
e
f
g

Posted information around the community

c
d
e
f
g

Presented to my colleagues

c
d
e
f
g

Presented to a community group

c
d
e
f
g

Conducted another type of presentation

c
d
e
f
g

None (skip to Question #6)

Other (please specify)

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HEALTHY NATIVE BABIES - OMB Number: 0925-0532/Expiration Date:
3. Approximate number of individuals reached through outreach efforts in the past
year?
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d
e
f
g

1-10

c
d
e
f
g

10-25

c
d
e
f
g

25-50

c
d
e
f
g

50-100

c
d
e
f
g

100 or more

c
d
e
f
g

None

4. What, if any, parts of the Healthy Native Babies Project training have you found to be
most helpful to bring the risk-reduction messages to your community?
c
d
e
f
g

Facts About SIDS

c
d
e
f
g

Strategies for Reaching Communities/Community Members

c
d
e
f
g

Hands-on Activities

c
d
e
f
g

Workbook, Resource CD and CD ROM Toolkit

c
d
e
f
g

Networking with Attendees

c
d
e
f
g

None

Other (please specify)

5. What, if any, of the Healthy Native Babies Project training can be improved?
c
d
e
f
g

Facts About SIDS

c
d
e
f
g

Strategies for Reaching Communities/Community Members

c
d
e
f
g

Hands-on Activities

c
d
e
f
g

Workbook, Resource CD and CD ROM Toolkit

c
d
e
f
g

Networking with Attendees

c
d
e
f
g

None

Other (please specify)

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HEALTHY NATIVE BABIES - OMB Number: 0925-0532/Expiration Date:
6. What challenges have you faced in bringing the SIDS risk-reduction information to
your community?
c
d
e
f
g

Limited resources

c
d
e
f
g

Lack of time

c
d
e
f
g

Language barriers

Other (please specify)

7. Please share any accomplishments you have achieved related to SIDS risk-reduction
activities since the Healthy Native Babies Project training.
5
6

8. Have you used the Healthy Native Babies Project Workbook since you attended the
training?
c
d
e
f
g

Yes

c
d
e
f
g

No

9. If no, please tell us why not? If yes, how have you used it?
5
6

10. Which files from the Resource CDROM have you used? (Check all that apply)
c
d
e
f
g

PowerPoint presentations

c
d
e
f
g

Activities

c
d
e
f
g

Articles/Reports

c
d
e
f
g

Graphics

c
d
e
f
g

None

11. Have you produced and distributed any of the following SIDS risk-reduction
materials? If yes, please check those that apply.
c
d
e
f
g

Flier

c
d
e
f
g

Postcards

c
d
e
f
g

Brochures

c
d
e
f
g

Posters

c
d
e
f
g

Other collateral

c
d
e
f
g

None

12. Have you created any materials using the Healthy Native Babies Project CDROM
Toolkit? If yes, please check those that apply.
c
d
e
f
g

Flier

c
d
e
f
g

Postcards

c
d
e
f
g

Brochures

c
d
e
f
g

Posters

c
d
e
f
g

Other collateral

c
d
e
f
g

None

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HEALTHY NATIVE BABIES - OMB Number: 0925-0532/Expiration Date:
13. If SIDS risk-reduction materials were obtained from another source, please list
below.
5
6

14. If you did not produce or distribute any SIDS risk-reduction materials, please tell us
why not?
5
6

15. In summary, do you have any suggestions that might help us to improve the Healthy
Native Babies Project?
5
6
Thank you for participating in this training, helping us to get the SIDS risk-reduction messages out in your community, and for helping us with
this survey!
*Public reporting burden for this collection of information is estimated to average 10 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
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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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN:
PRA (0925-0532). Do not return the completed form to this address.

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