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Hello:
You are invited to participate in our survey with (Parents of Asthmatic Children and Youth). In this survey, approximately (20-50) people will be asked to complete a survey that asks questions about (asthma medication compliance and the challenges parents have with inhalers).

Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw fom the survey at any point. It is very important for us to learn your opinions.

Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact [Kimberly Armstrong] at [800-485-8214] or by email at the email address specified below.

Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.

 
 
 
 
What is your gender?
 
Male
 
Female
 
 
 
What is your marital status?
 
Single (Never married)
 
Married
 
Domestic partnership
 
Widowed
 
Divorced
 
Separated
 
Don’t know
 
 
 
What is your age?
 
Younger than 18
 
18 - 24
 
25 - 34
 
35 - 44
 
45 - 54
 
55 - 64
 
65 or older
 
Prefer not to answer
 
 
 
Which category best describes your annual income?
 
Under $15,000
 
$15,000 - $29,999
 
$30,000 - $44,999
 
$45,000 - $59,999
 
$60,000 - $74,999
 
$75,000 - $89,999
 
$90,000 - $104,999
 
$105,000 - $119,999
 
$120,000 or more
 
Prefer not to answer
 
 
 
How many children do you have with asthma?
 
no children
 
1 child
 
2 children
 
3 children
 
more than 4 children
 
 
 
How often are visits to the doctor/hospital for asthma?
 
Weekly
 
Monthly
 
Yearly
 
 
Other
 
 
 
 
How many asthma inhalers do you have?
 
1 inhaler
 
2 inhaler
 
3 or more
 
 
 
How doe's your child/you keep up with the inhaler?
 
 
 
In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at school, or home?
 
All of the time
 
 
Most of the time
 
 
Some of the time
 
 
A little of the time
 
 
None of the time