Focus Group-3 Focus Group: Participant Information Form (Postpartum Wo

OMB Control No: 0915-xxx

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xpiration Date: xx-xx-20xx

TEXT4BABY PARTICIPANT INFORMATION (IF YOU ARE A NEW MOTHER)

Thank you for coming to talk with us today about text4baby. Before we begin talking, please take a few minutes to answer the questions below. We will not share any personal information. We will use information from this form to describe the groups of women we spoke with this week.

1. About how long ago did you sign up for text4baby messages?

MARK ONLY ONE

1 □ In the past 2 months

2 □ Between 3 and 6 months ago

3 □ Between 7 and 9 months ago

4 □ Between 10 and 12 months ago

5 □ More than 12 months ago 6 □ I don’t know

2. How old is your baby now?

MARK THE AGE OF YOUR YOUNGEST BABY

1 □ Less than 1 month old

2 □ 1 to 3 months old

3 □ 4 to 6 months old

4 □ 7 to 9 months old

5 □ More than 9 months old

3. When you decided to sign up for text4baby, how important were each of the following reasons?

MARK ONE BOX PER ROW

Reason	Very Important	Somewhat Important	Not Very Important
The messages are free.	□	□	□
The messages are convenient.	□	□	□
My doctor or midwife suggested I sign up.	□	□	□
A friend or family member suggested I sign up.	□	□	□
I wanted to get tips about having a healthy baby.	□	□	□
I wanted to get phone numbers to call for information about specific health topics.	□	□	□
I thought the reminders about well-baby care and other appointments would be helpful.	□	□	□

4. How often do you read your text4baby messages?

MARK ONLY ONE

1 □ Always

2 □ Usually

3 □ Sometimes

0 □ Never

5. How often do you learn something new from text4baby messages?

MARK ONLY ONE

1 □ Always

2 □ Usually

3 □ Sometimes

0 □ Never

6. How often do you share text4baby messages with friends or relatives?

MARK ONLY ONE

1 □ Always

2 □ Usually

3 □ Sometimes

0 □ Never

7. Have you ever called a phone number included in a text4baby message?

MARK ONLY ONE

1 □ Yes

0 □ No

8. Have you ever looked at the text4baby website or Facebook page?

MARK ONLY ONE

1 □ Yes

0 □ No GO TO QUESTION 10

9. How useful was the information on the tex4baby website or Facebook page?

MARK ONLY ONE

1 □ Very useful

2 □ Somewhat useful

3 □ Not very useful

10. During the past 12 months, have you had a flu shot?

MARK ONLY ONE

1 □ Yes

0 □ No

11. Did text4baby help you decide whether or not to get a flu shot?

MARK ONLY ONE

1 □ Yes

0 □ No

12. When your baby was born, did you breastfeed or feed pumped milk to your baby?

MARK ONLY ONE

1 □ Yes

0 □ No

13. When your baby was born, how did you usually lay your baby down to sleep?

MARK ONLY ONE

1 □ Side

2 □ Back

3 □ Stomach

14. Is there one person you think of as your baby’s personal doctor or nurse?

MARK ONLY ONE

1 □ Yes

0 □ No

15. During the past 12 months, did you see a dentist for preventive dental care, such as a check-up or dental cleaning?

MARK ONLY ONE

1 □ Yes

0 □ No

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0915-xxxx. The time required to complete this information collection is estimated to average 45 minutes per response. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

16. In general, how would you describe your health?

MARK ONLY ONE

1 □ Excellent

2 □ Very good

3 □ Good

4 □ Fair

5 □ Poor

17. Do you have any health coverage or insurance to help pay for your health care?

MARK ONLY ONE

1 □ Yes

0 □ No

18. How old are you?

| | | YEARS

19. Are you of Hispanic or Latino origin?

MARK ONLY ONE

1 □ Yes

0 □ No

20. What is your race?

MARK ALL THAT APPLY

1 □ American Indian/Alaska Native

2 □ Asian

3 □ Black or African American

4 □ Native Hawaiian or other Pacific Islander

5 □ White

Thank you for completing this form. The information you provided will help us evaluate the text4baby program.

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