Give Kids Sight Day Questionnaire

We are conducting a study that explores factors associated with parents seeking eye examinations for their children. We would be grateful if you would answer all the questions, to maximize the benefit of this questionnaire. All answers are confidential and the data will be used for research purposes only. Thank you for your time.

We are conducting a study that explores factors associated with parents seeking eye examinations for their children. We would be grateful if you would answer all the questions, to maximize the benefit of this questionnaire. All answers are confidential and the data will be used for research purposes only. Thank you for your time.

- Step 1 of 2

Background Information

1. Your Relationship to Child(ren) Being Screened *

• Parent
• Legal Guardian
• Grandparent
• Other

If Other, please specify:

2. What Is Your Gender? *

• Female
• Male
• Non-binary

3. Describe Your Race/Ethnicity *

• Asian/Asian American
• Black
• Latino/Chicano
• Native American/Alaska Native
• Pacific Islander
• White/European-American
• Other

If Other, please specify:

4. Marital Status

• Married
• Single Parent
• Divorced

5. How many children do you have? (including children not here today)

6. What barriers do you have to taking children to an eye doctor? (Check all that apply)

• Getting an appointment
• Transportation
• Medical costs
• Getting time off work
• Lack of insurance
• Language barrier
• Lack of available services
• Difficulty navigating the health system
• Childcare for other children
• None
• Other

If Other, please specify:

7. What health insurance do you have? (Check all that apply) *

• None
• Employer-sponsored
• Direct purchase or Marketplace or Healthcare.gov
• Medicaid
• Medicare
• Military
• Other

If other insurance, please specify

8. Are your children covered by your health insurance? *

• Yes, on my insurance
• No, on Children's Health Insurance Program (CHIP)
• No, on other insurance
• No, not on insurance

If on other insurance, please specify

9. Do you or your children have vision insurance *

• No
• Yes
• Don't know

10. Does your child/children currently have a pediatrician *

• Yes
• No

11. When was your child's last checkup with their pediatrician? *

• Never seen a pediatrician
• <6 months ago
• 6 months to 1 year ago
• 1-2 years ago
• 2-5 years ago
• More than 5 years ago

12. What motivated you to come today (Check all that apply) *

• My child has vision problems
• An eye doctor asked me to come
• A school employee asked me to come
• The pediatrician asked me to come
• My family asked me to come
• My friends asked me to come
• I have been here in a prior year
• The screening is for free
• Other

If other, please specify

13. How did you find out about the event today? (Check all that apply) *

• Online
• From my child's school
• From a poster or sign
• A primary care doctor
• From colleagues/family/friends
• Other

If other, please specify

14. How many children do you have being examined today? *

• 1
• 2
• 3
• 4
• 5+

Please click "Next" to answer a few questions about the child/children to be examined. 

 

Next

Child #1

 

1. Age

2. Child #1: Race/Ethnicity *

• Asian/Asian American
• Black
• Latino/Chicano
• Native American/Alaska Native
• Pacific Islander
• White/European-American
• Other

If other, please specify

3. Child #1: What is your reason for bringing the child in today? (Check all that apply) *

• Concerns about poor vision
• Concerns about eyes not straight
• Child complains of double vision
• Old eyeglasses broke
• Headaches
• Poor concentration/short attention span
• Poor school achievement and/or difficulty with literacy
• Other

If other, please specify

4. Child #1: Has your child failed a vision screening somewhere else? *

• Yes
• No

5. Child #1: When was the last time this child had an eye exam? *

• Never had an eye exam
• < 6 months ago
• 6 months to 1 year ago
• 1-2 years ago
• 2-5 years ago
• More than 5 years ago

6. Child #1: Has your child had regular eye examinations? *

• Yes
• No

7. Child #1: Were you every concerned that your child may have a vision problem? *

• Yes
• No

Child #2

1. Child #2: Age

2. Child #2: Race/Ethnicity *

• Asian/Asian American
• Black
• Latino/Chicano
• Native American/Alaska Native
• Pacific Islander
• White/European-American
• Other

If other, please specify

regular child/children not

3. Child #2: What is your reason for bringing the child in today? (Check all that apply) *

• Concerns about poor vision
• Concerns about eyes not straight
• Child complains of double vision
• Old eyeglasses broke
• Headaches
• Poor concentration/short attention span
• Poor school achievement and/or difficulty with literacy
• Other

4. Child #2: Has your child failed a vision screening somewhere else? *

• Yes
• No

5. Child #2: When was the last time this child had an eye exam? *

• Never had an eye exam
• < 6 months ago
• 6 months to 1 year ago
• 1-2 years ago
• 2-5 years ago
• More than 5 years ago

6. Child #2: Has your child had regular eye examinations? *

• Yes
• No

Submit