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Pilot Participants for the Small Steps to Eye Care Action Plan: A Conversation Guide

Thank you for piloting the Small Steps to Eye Care Action Plan: A Conversation Guide. For this step, we are collecting demographic information on Pilot Participants. After you complete the questions, you will receive a draft copy of the Action Plan and another SurveyMonkey questionnaire to tell us your thoughts about the Action Plan after you use the Action Plan with one or more families.

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* 1. Please provide your contact information

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* 2. Your title

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* 3. Your credentials

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* 4. Please describe where you work (check all that apply)

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* 5. What are the demographics of your students/clients? Check all that apply

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* 6. If you serve tribal, immigrant, refugee or migrant populations, please list names of tribes and/or countries of origin of the children in your school/program.

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* 7. Please tell us about yourself. Check all that apply

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* 8. For how long have you been working with families whose child received a referral from a vision screening?

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