Questionnaire

Date *

Last name *

First name *

Affiliation and Department of Institute *

(Please provide exact affiliation for publication)

Country *

Region

Email *

Phone *

What is your profession? *

What is your role in screening? *

How many years have you been working or otherwise been involved in screening? *

Do you perform general or vision or hearing screening yourself? If yes, please specify

No

YesYes

Do you supervise vision or hearing screening? If yes, please specify

No

YesYes

Do you follow up children after screening? If yes, please specify

No

YesYes

Are you involved in organizing screening ? If yes, please specify

No

YesYes

Are you reporting data for the whole country or a specific area?

NationalNational

RegionalRegional

Local (sub-regional)Local (sub-regional)

OtherOther

If national data differ from regional data and you are well informed about the differences, you will need to fill out two forms, or two Country Representatives have to fill out two forms. For instance, in the United Kingdom four Country Representatives may be needed to fill out four forms for Northern Ireland, Scotland, Wales and England. If you fill out the questionnaire for a region, it is tacitly assumed that all answers apply to the selected region. Otherwise it should be explicitly mentioned. For instance, mortality rate is usually reported per country. Please specify which region at "Other".

EUSCREEN Paediatric Screening Questionnaire