Prenatal Survey – Survey 1 (Pre)

Thank you for taking our survey.

Please take a few minutes to complete this prenatal survey so that we can provide books and literacy information for you and your baby. We ask you to complete your personal information, followed by some true or false questions. Please complete all required questions (marked by an asterisk). Your answers will be kept completely confidential.

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(* denotes required fields)

Today’s Date:*

First Name:*

Last Name:*

Address:*

Address 2:

City:*

State:

CONNECTICUT

ZIP Code:*

County:*

Home/Mobile Phone:*

Email:*

What year were you born?*

Location of care:*

Is this the first time you received information from Read to Grow?*

1. A baby is ready to learn from birth.*

2. Parents are a baby's first teachers.*

3. Brain development is greatest in a person’s first 3 years of life.*

4. Sharing books and reading with a baby stimulate the brain and language skills.*

5. Talking and reading increase a child's vocabulary (words the child knows).*

6. Screen time (such as TVs, phones, tablets or computers) is not recommended for children under age 2.*

7. Main language spoken at home:*

8. If other language, please specify.

9. How many children do you have at home?*

If you are pregnant with your first child, you have finished the survey. Thank you! If you have children, please complete the next set of questions.

10. At what hospital was your child/children born?

11. Did you receive in the hospital a free packet with a baby book and parents' guide from Read to Grow?

12. Children's books are shared or read at home with my child/children:

13. In my home, we have this number of children's books:

Before submitting your form, please make sure all required fields are completed.

Once you click “Submit,” you should see a message that says “Thank you for Completing Our Survey!” This confirms that your request went through.

If you do not see the “thank you” message, your request was not submitted successfully. Please double-check the form and try again.

Thank you for your time and care in completing our survey.

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Name:*

First Last

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Mailing Address:*

Street Address City State ZIP Code

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Home Phone Number:

Prenatal Survey – Survey 1 (Pre)

If you are pregnant with your first child, you have finished the survey. Thank you! If you have children, please complete the next set of questions.

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