ATLANTA AND CHICAGO DIAPERS 1. Question Title 1. During the 12-day study, you would be asked to complete a questionnaire after removing each diaper. You would need to return the used diapers (in bags provided) and paperwork to our agency during normal business hoursd. We are looking for Step/ size Newborn and Step / size 1. Do you have a child that wears one of these sizes and you can not have participated in a diaper study in the last 3 months. YES NO Question Title 2. Please complete the contact information below. First and Last Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title 3. Please supply us with a secondary contact number. Murray Hill Center standard policy requires at least two contact numbers for each respondent. If the secondary number you give us is not your own number but a friend, family member or co-worker please indicate as such. Question Title 4. What is your gender? Male Female Question Title 5. What is your current age? Question Title 6. What is your ethnicity? Caucasian African American / Black Asian American Indian / Native American Hispanic / Latino Other (please specify) Question Title 7. What is your current work status? Full-Time Employed Part-Time Employed Homemaker Unemployed / Looking for work Retired Student Full-Time Question Title 8. What is your Occupation-Job Title, Company you work for, and Industry? (If you are Retired, Unemployed or a Homemaker Please tell us your previous employment information. If you are a full-time student please enter your Grade, School and Major) Occupation: Company: Industry: Question Title 9. 8. What is the highest level of education that you have completed? Some High School or less High School Graduate or GED Some College - No degree 2 yr College Degree / Associates 4 yr College Degree / Bachelors Post Graduate Work / Degree Question Title 10. 9. What is your current marital status? Single - Never Married Single - Divorced Single - Widowed Single - Separated Live with Partner / Co-Hab Married Question Title 11. For this study, we are interested in speaking with people who work in certain occupations. For this reason, we need to know for what companies you or any other members of your household work. Daycare (for infant and child care only) Advertising Agency Market Research Firm TV, Newspaper, or Radio Station Procter & Gamble Kimberly-Clark First Quality SCA - Svenska Cellulosa Aktiebolaget Associated Hygienic Products Irving Personal Care Arquest Question Title 12. Do you have a child at home currently wearing diapers? YES NO Question Title 13. Which type of diapers do you use for your child? Cloth only Cloth and disposable Disposable only Disposable Training Pants Question Title 14. Would you please tell me the size of diapers that your child is currently using? Step/size Newborn [ ] Step/size 1 [ ] Step/size 2 [ ] Step/size 3 [ ] Step/size 4 [ ] Step/size 5 Question Title 15. Do you anticipate that your child will be wearing a Step 1/Size 1 disposable diaper during the study dates of 6 – 18 February 2015? YES NO Question Title 16. What is your child’s current weight (approximately)? Question Title 17. Is your child in good general health? YES NO Question Title 18. . What brand of disposable diapers have you used most often during the past 30 days? Huggies (Step/Size 1) (Pure & Natural / Little Snugglers / Snug & Dry) Pampers (Step/Size 1) (Swaddlers / Swaddlers Sensitive / Baby Dry) All other Brands, including Luvs Question Title 19. Is your baby a boy or a girl? BOY GIRL Question Title 20. Does your baby have a chronic skin condition (eczema, psoriasis etc.)? YES NO Question Title 21. . Does your child have known allergies or skin sensitivities to disposable absorbent products or their materials/components, cosmetics or fragrance ingredients? YES NO Question Title 22. What type of daycare does your child attend, if any? Does not attend Someone comes to my home [ ] Someone else’s home [ ] Daycare center (public, church or company) Question Title 23. It would be your responsibility to instruct any of your child’s care givers on how to follow the same study procedures as we will ask of you. Would you be willing to instruct your child’s care provider of these procedures? YES NO Next
