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  2. 2005
  3. May
  4. S
  5. Sample Survey
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Hello:

You are invited to participate in our survey [Project Description Here]. In this survey, approximately [Approximate Respondents] people will be asked to complete a survey that asks questions about [General Survey Process]. It will take approximately [Approximate Time] minutes to complete the questionnaire.


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 from the survey at any point. It is very important for us to learn your opinions.


Your survey responses will be stricly 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 [Name of Survey Researcher] at [Phone Number] 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.
 
 
 
Favorite Drink...
 
Coke
 
Pepsi
 
Mountain Dew
 
 
 
Additional Comments/Suggestions for improvement
   
 
 
To what extent have you participated in the following activities?
Please select one response.
I modify my home to accommodate my child.
Never Rarely Sometimes Often Always
 
 
Please select the response that best describes how much you agree or disagree with the statement.
Strongly Disagree Disagree Neither Disagree nor Agree Agree Strongly Agree
* I know what I need, what I like, and what I am good at.
* I set goals to get what I want or need. I think about what I am good at when I do this.
* I figure out how to meet my goals. I make plans and decide what I should do.
* I begin working on my plans to meet my goals as soon as possible.
* I check how I am doing when I�m working on my plan. If I need to, I ask others what they think of how I am doing.
* If my plan doesn't work, I try another one to meet my goals.
* People listen to me when I talk about what I want, what I need, or what I am good at.
* People let me know that I can set my own goals to get what I want or need.
* I have learned how to make plans to meet my goals and to feel good about them.
* People encourage me to start working on my plans right away.
* I have someone who can tell me if I am meeting my goals.
* People understand when I have to change my plan to meet my goal. They offer help and encourage me when I am doing this.
 
 
Please check all that apply.
Which of the following items are obstacles to your advocacy efforts on behalf of your child at this time?
 
Child care
 
Emotions
 
Finances
 
Health care
 
Inadequate information
 
Job related issues
 
Professionals
 
Social reaction
 
Special education system
 
None

 
 
 
Hello:

You are invited to participate in our survey [Project Description Here]. In this survey, approximately [Approximate Respondents] people will be asked to complete a survey that asks questions about [General Survey Process]. It will take approximately [Approximate Time] minutes to complete the questionnaire.


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 from the survey at any point. It is very important for us to learn your opinions.


Your survey responses will be stricly 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 [Name of Survey Researcher] at [Phone Number] 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.
 
Please contact [email protected] if you have any questions regarding this survey.
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