Speech-Language Initiative

Pre-Implementation Survey

Families chosen to receive a Read-Along Songs set are asked to participate in this short survey about reading. Families must give (written or verbal) permission to complete the survey before they receive their set and again in 3 to 6 months. Please emphasize that all information collected will remain anonymous and confidential and will be reported to Family Reading Partnership only. All fields are required.

Please check what type of permission you received from the family to participate in the Read-Along Songs Initiative:	Verbal    Written
SLP Initial code for family:	(e.g. SLP Initials, #)
Adult answering the survey
Age:
Gender:	Female    Male
Education Completed:
Do you remember being read to as a child?	Yes    No
Do you regularly read newspapers, magazines, books, or read for entertainment online?	Yes    No
Child receiving speech services
Age:
Gender:	Female    Male
Has your family seen the Read-Along Songs books or CD, or attended a performance before today?	Yes    No
Do you listen to music made for children as a family activity?	Yes    No
Does the child look at books independently?	Yes    No
Does the child request reading as an activity?	Yes    No
How often do you sit with your child and read books?	0-2 times per week 3-4 times per week 5-7 times per week Multiple times daily
Other information offered:

If you have any questions, please contact Lisa Berry by phone at 607-277-8602 or via email at lisa@familyreading.org.