1. Your Rights and Consent to Participate in the Evaluation of Imagination Library in Onondaga County

At this time, your consent is being sought to participate in our research to learn if the Imagination Library is successful.  Please read the following information carefully before you decide whether or not to consent to participate. Your responses will be kept confidential and will be available only to professional researchers and staff. The researchers include Monica Sylvia Ph.D. and Frank Ridzi Ph.D. If the results of this study are published, the data will be presented in group form and individual participants will not be identified. Completion of the following survey indicates you are over 18 years of age, have read your rights and consented to participate. This research has been reviewed and approved by Le Moyne College's Institutional Review Board. You will be asked to respond to a few survey questions.  The risks in this study are minimal and are no greater than those ordinarily encountered in daily life. You may choose not to answer any question(s) that make(s) you uncomfortable, and you do not need to complete this survey to continue receiving Imagination Library Books. However, your participation will help us to improve the program. In compliance with federal guidelines, all hardcopy and electronic records related to this research will be retained in secure storage at Le Moyne College or on a secure Le Moyne College server for at least three years after the research has been completed. Data will be stored on the Survey Monkey website until the completion of this research project. Whenever one works with email or the internet, there is always the risk of compromising privacy, confidentiality, and/or anonymity. Your confidentiality will be maintained to the degree permitted by the technology being used. It is important for you to understand that no guarantees can be made regarding the interception of data sent via the internet by third parties. Questions regarding this research itself should be directed to the researchers at (315) 883-5553. Questions or concerns regarding your rights as a research participant should be directed to the co-chairs of the Institutional Review Board. They can be reached at irb@lemoyne.edu or phone number 315-445-4349. If you decline to answer this survey, scroll to the bottom and click next until it brings you to the end of the survey and then click done. Thank you so very much!

* 1. What is your email address (note an email address is required for online registration)?

* 2. What is the first name of the child you are registering?

* 3. What is the last name of the child you are registering?

* 4. What is the date of birth for the child you are registering?

Enter date here in the following format MM/DD/YYYY

* 5. What is today's date?

Enter date here in the following format MM/DD/YYYY

* 6. How many times have you or someone in your house read to your child in the past 7 days?

* 7. When you or someone in your house reads to your child, how often do you: Stop reading and ask your child to tell you what is in the picture?

* 8. When you or someone in your house reads to your child, how often do you: Stop reading and ask what a letter is?

* 9. When you or someone in your house reads to your child, how often do you: Ask your child to read with you?

* 10. When you or someone in your house reads to your child, how often do you: Talk about the story and ask your child questions about the story?

* 11. In the past seven days, how many times has your child asked that you read to him or her?

* 12. In the past seven days, how often has your child spent time looking at books by himself?

* 14. What is your race?

* 15. What country were you born in?

* 16. Do you have long-term housing that you can afford?

* 17. Do you feel safe in your neighborhood?

* 18. Do you have enough food?

* 19. Do you pay for your own housing and food without government support?

* 20. Do you have dependable and safe transportation when you need it?

* 21. Do you have clothes that are okay for work school and local weather?

* 22. Do you have enough money to meet basic needs and pay bills on time?

* 23. Do you save some money for future needs?

* 24. Do you have a stable full-time job?

* 25. Do you have health insurance for you and your family?

* 26. Do you know how to get help if someone in your family needs mental or emotional health care?

* 27. Do your family members ever make you feel unsafe?

* 28. Can you get good quality childcare if you need it?

* 29. Can you get legal help if you need it?

* 30. Do you have the skills you need to get the kind of jobs you want?

* 31. Do you have a high school diploma or an equivalency diploma (such as a GED)?

* 32. Do you know how to get more education if you want it?

* 33. Can you say you had no problems with addiction in the last year?

* 34. Has your home or child been tested for lead?

* 35. What needs do you have that are not listed above?

* 36. What type of organization referred you to Imagination Library?