Parent Focus Group Screening Survey

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* 1. Please give basic information

Name

City/Town

State/Province

Email Address

Phone Number

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* 2. How old is your child with special learning or healthcare needs?

1

18

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 3. Please briefly describe your child’s disability or condition.

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* 4. Please describe the eye care and treatment your child has received or is currently receiving.

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* 5. At what age did your child first receive an eye exam?

0

18

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 6. Please indicate your best times for participating in our focus group.

Weekday mornings

Weekday afternoons

Weekday evenings

Weekends

Other (please specify)