4 Parent/Guardian Interview Survey

OMB Number: 0925-0648

Expiration Date: 01/31/2015

Noisy Planet Mall Interviews

PARENT/GUARDIAN INTERVIEW SURVEY

Fact Sheet Titled “Hearing Health for Your Children”

FACT SHEET DESIGN

1. Please take a look at these two fact sheets. Based ONLY on the “look and feel” of these fact sheets—meaning the colors, visuals, and layout—which one do you like better?

( ) Blue “wave” fact sheet

( ) Blue “grid” fact sheet

Now, focus ONLY on the fact sheet that you said you liked better.

2. On a scale of 1 to 5, where “1” is “poor” and “5” is “excellent,” what is your opinion of the format/layout of this fact sheet? (Circle one number.)

1 ………. 2 ………. 3 ………. 4 ………. 5

Poor ……….………………….…….. Excellent

3. On a scale of 1 to 5, where “1” is “poor” and “5” is “excellent,” what is your opinion of the colors in this fact sheet? (Circle one number.)

1 ………. 2 ………. 3 ………. 4 ………. 5

Poor ……….………………….…….. Excellent

4. On a scale of 1 to 5, where “1” is “poor” and “5” is “excellent,” what is your opinion of the visuals/images in this fact sheet? (Circle one number.)

1 ………. 2 ………. 3 ………. 4 ………. 5

Poor ……….………………….…….. Excellent

4a. What is one thing that you would change to the fact sheet’s “look and feel”?

________________________________________________________________

FACT SHEET INFORMATION—GENERAL COMMENTS

Now, please take a few moments to read the entire fact sheet that you said you liked better.

[Interviewer: Note the approximate amount of time that the respondent took to read the fact sheet: _____ minutes.]

5. On a scale of 1 to 5, where “1” is “very difficult to read” and “5” is “very easy to read,” how easy was the fact sheet to read? (Circle one number.)

1 ………. 2 ………. 3 ………. 4 ………. 5

Very difficult to read ………….… Very easy to read

6. Do you believe the information in the fact sheet?

( ) Yes

( ) No

7. How likely are you to use this information with your child?

( ) Very likely

( ) Somewhat likely

( ) Somewhat unlikely

( ) Very unlikely

( ) I don’t know

8. Will you encourage your child to take actions based on the information you read in this fact sheet?

( ) Yes

( ) No

8a. If yes, what actions will you encourage your child to take based on the information you read in this fact sheet?

_________________________________________________________________________

9. Would you visit the website listed in this fact sheet (www.noisyplanet.nidcd.nih.gov)?

( ) Yes

( ) No

10. Would you call the 800 number listed in this fact sheet (800-241-1044)?

( ) Yes

( ) No

FACT SHEET INFORMATION—SPECIFIC CONTENT

The next questions are not to test you but to test how well the fact sheet is written. [The respondent is welcome to review the fact sheet while answering the next questions.]

11. In your own words, what is this fact sheet trying to tell you?

__________________________________________________________________________

12. Noise-induced hearing loss is caused by:

( ) Long or repeated exposure to very quiet sounds.

( ) Long or repeated exposure to loud sounds. [CORRECT]

13. Noise-induced hearing loss is preventable—true or false?

( ) True [CORRECT]

( ) False

14. Noise-induced hearing loss always affects both ears—true or false?

( ) True

( ) False [CORRECT] (Noise-induced hearing loss can affect one ear or both ears.)

15. Research has shown that adolescents listen to their parents and model their parents’ behavior—true or false?

( ) True [CORRECT]

( ) False

16. Which of the following can protect your child’s hearing? [Interviewer: Read aloud all response options.]

( ) Wearing hearing protectors.

( ) Moving away from the noise.

( ) Lowering the volume.

( ) All of the above. [CORRECT]

17. Who is the sponsor of this fact sheet?

____________________________________________________________________________

[CORRECT RESPONSE: U.S. (Federal) Government, U.S. Department of Health and Human Services, National Institutes of Health (NIH), National Institute on Deafness and Other Communication Disorders (NIDCD) (any of these is correct)].

WEBSITE PAGE

Thank you for your answers so far. I only have a few more questions.

18. Please take a brief look at these sample website page(s). On a scale of 1 to 5, where “1” is “not at all” and “5” is “a lot,” how much do you like these website pages?

Website Page A (Circle one number.)

1 ………. 2 ………. 3 ………. 4 ………. 5

Not at all ……….………………….…….. A lot

Website Page B (Circle one number.)

1 ………. 2 ………. 3 ………. 4 ………. 5

Not at all ……….………………….…….. A lot

19. What is one thing that you would change on Website Page A?

____________________________________________________________________________

19a. What is one thing that you would change on Website Page B?

______________________________________________________________________

20. Would you visit this Web page?

( ) Yes

( ) No;

20a. Why not? _____________________

21. Would you share this Web page with other people, such as friends, other parents, family members, school teachers, or doctors?

( ) Yes

( ) No;

21a. Why not? _____________________

MOBILE APP

22. Where does your adolescent child get most of his or her information about healthy living? ______________________________________________________________________________

(Examples: School, parents, friends, other family members, pediatrician/other doctor, television, books, smartphone, Internet)

23. Does your adolescent child have access to a smartphone?

( ) Yes; _____________________

( ) No

23a. Who decides which apps to download for his/her use?

24. Would you encourage your adolescent child to use an interactive app on protecting his or her hearing?

( ) Yes

( ) No;

24a. Why not? _____________________

25. Would you install a mobile app on your (or your child’s) smartphone that tells you when the noise or sound around you is too loud and could damage your hearing?

( ) Yes

( ) No;

25a. Why not? _____________________

Thank you so much for your time. Your valuable feedback will help improve

the National Institutes of Health education materials.

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^* Public reporting burden for this collection of information is estimated to average15 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 Office of Management and Budget control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: National Institutes of Health, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0648). Do not return the completed form to this address.