| 1. |
Your gender |
O Female |
O Male |
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| 2. |
Your age |
_____ years old |
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| 3 |
I am the child’s |
O Mother |
O Father |
O Relative:
_______ |
O Other: _______ |
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| 4. |
What is the highest level of education the Mother has completed? |
O Primary school (6th grade) |
O Middle school (7th, 8th or 9th grade) |
O Some high school |
O Some post-high school education |
O College graduate |
O Graduate degree |
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| 5. |
What is the highest level of education the Father has completed? |
O Primary school (6th grade) |
O Middle school (7th, 8th or 9th grade) |
O Some high school |
O Some post-high school education |
O College graduate |
O Graduate degree |
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| 6. |
What is your current occupational status? |
O Student |
O Work part-time |
O Work full-time |
O Unemployed |
O Retired |
O Disabled |
O Other: _______ |
| 7. |
Which of the following categories best describes the annual household income? |
O $ 10,000 to $ 19,999 |
O $ 20,000 to $ 34,999 |
O $ 35,000 to $ 50,999 |
O $ 51,000 to $100,000 |
O Over $100,000 |
O I do not wish to respond |
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| 8. |
Which of the following describes your ethnic / racial background? |
O White |
O Black |
O Asian or Pacific Islander |
O Aleut, Eskimo, or Native American |
O Hispanic or Latino |
O Other: _______ |
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| 9. |
Have you had a skin cancer in the past? |
O No |
O Yes |
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| 10. |
I am at risk of developing a skin cancer. |
O Strongly disagree |
O Disagree |
O Undecided |
O Agree |
O Strongly Agree |
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| 11. |
My skin is sun sensitive. |
O Strongly disagree |
O Disagree |
O Undecided |
O Agree |
O Strongly Agree |
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| 12. |
How confident are you that you know the best sunscreen for your child to use? |
O Not at all Confident |
O Slightly Confident |
O Somewhat Confident |
O Very Confident |
O Extremely Confident |
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| 13. |
What is the age of this child? |
O 2 up to 3 years old |
O over 3 up to 4 years old |
O over 4 up to 5 years old |
O over 5 up to 6 years old |
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| 14. |
This child is a: |
O Boy |
O Girl |
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| 15 |
My child’s skin is sensitive to the sun. |
O Strongly disagree |
O Disagree |
O Undecided |
O Agree |
O Strongly Agree |
| 16. |
If after several months of not being in the sun, your child stayed outdoors for 1 hour at noon for the first time in the summer without sunscreen, what would happen to your child’s skin? |
O Always sunburn with painful red skin 24 hours after being in the sun |
O Easily sunburn with red or pink skin 24 hours after being in the sun |
O Sometimes sunburn or get skin irritation from being in the sun |
O Rarely sunburn or get skin irritation from being in the sun |
O Never sunburn or get skin irritation from being in the sun |
| 17. |
Seven days after the first time in the sun in the summer, would your child develop a tan or would you notice the child’s skin becoming darker? |
O Never tan |
O Minimally tan orthesun-exposedskinbecomesminimallydarker |
O Easily tan orthesun-exposedskineasilybecomesdarker |
O Always tan orthesun-exposedskinalwaysbecomesdarker |
O The skin is dark and does not get darker after being in the sun. |
| 18. |
I intend to redeem the coupon for a swim shirt for my child. |
O Yes |
O No, wewouldnot use it. |
O No, wealready use a swimshirt/rashguard. |
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