Survey

Circle your gender

Male             Female

Do you know someone who has been born with any type of birth defect?

Yes              No

Do you know about the different types of birth defects a child can be born with?

Yes                 No

Every thirty seconds a child is born with a birth defect.

True             False

When having a child with a birth defect, who does it effect the most?

1. Mother
2. Father
3. Both equally
4. None

Please range the following in order of importance. Greatest to Least

Hernias  Down Syndrome  sexually transmitted diseases  Fetal Alcohol Syndrome 1.

2.

 3.

4.

It is important for a mother to know her child will be born with a type of defect?

1. Strongly Agree
2. Agree
3. Strongly Disagree
4. Disagree

How important is it on a scale 1-10 to be informed about the different birth defects?

1   2   3   4   5   6   7    8   9   10

Please briefly answer the following question in the space provided below it.

How would you feel if a doctor told you your child will be normal but was born abnormal?

One out of ______ babies are born with birth defects.

1. 10
2. 30
3. 33
4. 5

It can emotionally hurt parent to know their child is born with a defect and the doctor did not know anything about it.

A Strongly Agree

B. Agree

C. Strongly Disagree

D. Disagree