SBA Survey

	Are you at least 18 years old?
		Yes
		No

	What is your zip code?
		USA (Type in zip code) After entering your zip code, click here to continue
		Other Country

		Which of the following BEST describes you:
	Do you know of a local Spina Bifida Association?
		Yes
		No

	Do you participate in activities of the local Spina Bifida Association, its support groups, or associated clinic?
		Yes
		No

	What is your relationship to the Spina Bifida community?
		Adult living with Spina Bifida
		Parent of a child with Spina Bifida
		Other relative of a person living with Spina Bifida
		Caregiver of a person living with Spina Bifida
		Health care professional
		Other volunteer or professional

	How did you first learn about Spina Bifida Association?
		The Internet
		Radio Ad
		Media
		Referral from a friend
		Referral from a Health Care provider
		Other Click here to continue

	Are you currently? (Check the BEST answer)
		Employed for wages
		Self-employed
		Out of work for more than 1 year
		Out of work for less than 1 year
		Homemaker
		Student
		Retired
		Unable to work

	What is your age in years?
		(Type in age) After entering your age click here to continue

	What is your race/ethnicity?
		White
		Latino or Hispanic
		American Indian/Alaskan Native
		Asian/Pacific Islander
		Black/African American
		Other race/ethnicity (please specify) After entering click here to continue

	What is the highest grade or year of school you completed? (Check the BEST answer)
		Never attended school or only kindergarten
		Grades 1 through 8 (Elementary)
		Grades 9 through 11 (Some high school)
		Grade 12 or GED (High school graduate)
		College 1 year to 3 years (Some college or technical school)
		College 4 years or more

	Which of the following best describes your total annual household income?
		Under $25,000
		$25,001 - $50,000
		$50,001 - $75,000
		$75,001, - $100,000
		Over $100,000
		I prefer not to answer this question

	When you need information related to Spina Bifida, which of the following do you use? (Select all that apply)
		Conduct an Internet Search
		Ask my health care provider
		Consult my local Spina Bifida Association chapter
		Consult my local Spina Bifida clinic
		Call Spina Bifida Association
		Visit Spina Bifida Association website, www.spinabifidaassociation.org
		Other
		Click here to continue

	Are you using SBA's online Resource Directory, available at www.spinabifidaassociation.org?
		Yes
		No
		Not familiar with this

	Are you familiar with Insights, a magazine published by SBA?
		Yes
		No
		Don't Know

	If a company or brand advertises in Insights magazine, this affects my view of their company and likelihood to buy their products:
		Positively
		Neutral
		Negatively

	Seeing that a company supports SBA or participates in SBA's activities and programs wins my trust.
		True
		Somewhat True
		False

	I would choose products that advertise of support SBA over others that do not.
		True
		Somewhat True
		False

	For me, the most important aspect of SBA's work is: (Select all that apply)
		Education
		Advocacy
		Research
		Service
		Outreach Programs
		Prevention Programs
		Quality of Life Programs
		Click here to continue

	I attend a _________ Spina Bifida Association Conference:
		Local
		Regional
		National
		None of the above
		Click here to continue

	If I am choosing between two brands that are about the same in price and quality, I am very/somewhat likely to switch to the company/brand that suppports Spina Bifida Association's national conference.
		Very likely to switch
		Likely
		Somewhat likely
		No effect

	The Spina Bifida Association hosts several ListServs (SB Parents, Occulta, Youth and Adult Alliance (YAA), and Nursing and Healthcare Professional Council (NHPC)). Are you familiar with or subscribed to any of them?
		Yes
		No

	Do you have Spina Bifida?
		Yes
		No

	Managing multiple medical appointments can be challenging. How do you keep track of your medical appointments? Check all that apply.
		My Case Manager or Social Worker helps me make and keep track of appointments.
		I use a calendar to make and keep track of appointments.
		I use a computer or a palm pilot to make and keep track of appointments.
		A family member helps me make and keep track of appointments.
		I use the Health Care Record in the Health Guide for Adults Living with Spina Bifida
		Other
		Click here to continue

	What is your gender?
		Female
		Male

	Do you have a personal history of pregnancies affected by neural tube defects? (e.g. ever had a pregnancy affected by neural tube defects)
		Yes
		No

	Do you have a child/children with Spina Bifida?
		Yes
		No, I do not have any children
		No, my child/children do not have Spina Bifida

	How old is your child in years? (If you have multiple children with Spina Bifida, please separate the ages with a comma (,).
		(fill in age, eg. 7 not "7 yrs old") After typing in age click here to continue

	How likely are you to become pregnant?
		I'm pregnant now
		I'm likely to be pregnant soon (within 1-3 months)
		I'm likely to become pregnant sometime in the future
		I don't know/I'm undecided
		I don't plan to be pregnant now or at anytime in the future
		I have a medical condition, such as a hysterectomy, that makes pregnancy impossible

	Some health care providers recommend that women of childbearing age take folic acid everyday in order to reduce the chances of neural tube defects. Has your health care provider made this recommendation before?
		Yes
		No
		Don't know

	How often do you take folic acid?
		Never
		1-3 times a week
		4-6 times a week
		Everyday

	How much folic acid are you taking? (Choose the closest amount)
		100 mcg (.10 mg)			900 mcg (.90 mg)
		200 mcg (.20 mg)			1000 mcg (1.0 mg)
		300 mcg (.30 mg)			2000 mcg (2.0 mg)
		400 mcg (.40 mg)			3000 mcg (3.0 mg)
		500 mcg (.50 mg)			4000 mcg (4.0 mg)
		600 mcg (.60 mg)			5000 mcg (5.0 mg)
		700 mcg (.70 mg)			Don't know
		800 mcg (.80 mg)

	How much folic acid should women who have a history of neural tube defects take?
		1000 mcg (1.0 mg) before trying to become pregnant
		2000 mcg (2.0 mg) before trying to become pregnant
		3000 mcg (3.0 mg) before trying to become pregnant
		4000 mcg (4.0 mg) before trying to become pregnant
		5000 mcg (5.0 mg) before trying to become pregnant
		Don't know exact amount
		None of these amounts

	What is your specialty?
		Obstetrics/Gynecology
		Family practice
		Pediatrics
		Physical Therapy
		Occupational Therapy
		Nurse/Nurse Practitioner
		Other (please specify) After typing in your response, click here to continue

	Each month, approximately how many women do you see who are at increased risk for Spina Bifida or NTDs?
		Less than 10 women
		11-20 women
		More than 20 women
		Not applicable

	How often do you mention folic acid to women during routine visits?
		All the time
		Sometimes
		Not very often
		Never/not applicable

	Are you familiar with the ABCs of Folic Acid Counseling, a tutorial developed by the Spina Bifida Association?
		Yes
		No

	Which of the following amounts of folic acid does the US Public Health Service recommend for women who are at an increased risk for neural tube defects and planning a pregnancy?
		1000 mcg (1.0 mg)
		2000 mcg (2.0 mg)
		3000 mcg (3.0 mg)
		4000 mcg (4.0 mg)
		5000 mcg (5.0 mg)

	Would you consider joining a multidisciplinary professional forum dedicated to Spina Bifida research and care?
		Yes
		No

	Have you seen messages in the media or your community about Spina Bifida and folic acid?
		Yes
		No
		Don't know

	If yes, where was the information? (Check all that apply)
		Radio
		TV
		Internet
		Newspaper or magazine
		Community center
		Doctor's office/clinic
		Other, please specify Click here after answering to continue

	We are looking for ways to revise this survey in the future. Which type of survey would you prefer to complete? Please select the ONE that you would like best.
		Paper and pencil survey sent via mail
		Web survey
		Telephone survey

	How would you like to be invited to complete the survey? Check all that apply.
		Receive a postcard in the mail
		Receive an email invitation
		Announcement posted on SBA's website
		Click here after answering to continue

	Where would you be most likely to see our survey promotion? Check ALL that apply.
		Websites	(fill in blank)
		Listservs	(fill in blank)
		Newsletters	(fill in blank)
		Other	(fill in blank)
		Click here after answering to continue

	Can you suggest the names of groups or organizations that might help us reach other people touched by Spina Bifida?
		Yes	(fill in blank)
		No
		Click here after answering to continue

	What are the best ways for us to share the results of this Community Survey?
		Websites	(fill in blank)
		Listservs	(fill in blank)
		Newsletters	(fill in blank)
		Conference presentations	(fill in blank)
		Other	(fill in blank)
		Click here after answering to continue

	In order to be entered into the drawing for the gift certificate and to compare the survey responses while keeping your name confidential and private, we need your email address. Your email address WILL NOT be shared with other organizations or used for any marketing purposes. We will use your email address only to compare the results to previous research and will contact you only about the survey.
		Enter email
		I do NOT want to share my email. I understand that I will not be entered in the gift certificate drawing.
		After you enter your email click here to continue

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your responses to our database.