Parental Awareness and Attitudes Regarding Safety and Radiation Associated With
Medical Imaging Techniques Commonly Ordered in the Pediatric Emergency
Department
Study Code_____
1. What is your age? ______ years
2. What is your gender? (Circle one) Female1
Male2
3. What is your ethnicity? (Circle one)
Caucasian1
African American2 Hispanic/Latino3
Other5 (please specify)__________
Asian/Pacific Islander4
4. What is your highest level of education? (Circle one)
Some high school1
Completed high school2
Associates Degreee
Degreee
Bachelors
5. How old is your child that is getting medical imaging? _____ years
6. Why did you bring your child into the emergency department?
________________________________________________________________________
________________________________________________________________________
7. What type or types of medical imaging is your child having done?
(Circle all that apply)
CT scan
MRI
X-ray
8. In your child’s life how many of each has he/she had done before today?
CT scans______
MRIs_____ X-rays_____
9. Which of these imaging methods do you feel is the safest?
(Circle one) CT scan1
MRI2
X-ray3
Don’t know
10. Which of these imaging methods do you feel is the least safe?
(Circle one) CT scan1
MRI2
X-ray3
Don’t know
11. Which of these imaging methods do you feel gives off the most amount of radiation?
(Circle one) CT scan1
MRI2
X-ray3
Don’t know
12. Which of these imaging methods do you feel gives off the least amount of radiation?
(Circle one) CT scan1
MRI2
X-ray3
Don’t know
13. Please tell me up to 3 negative effects that you think CT scans may have on patients
starting with the most severe.
1.__________________________
2. __________________________
3. __________________________
14. How many CT scans would it take for a patient to experience any negative effect?
_________ CT scans
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Parental Awareness and Attitudes Regarding Safety and Radiation Associated With
Medical Imaging Techniques Commonly Ordered in the Pediatric Emergency
Department
15. Please tell me up to 3 negative effects that you think MRIs may have on patients
starting with the most severe.
1.__________________________
2. __________________________
3. __________________________
16. How many MRIs would it take for a patient to experience any negative effect?
_________ MRIs
17. Please tell me up to 3 negative effects that you think X-rays may have on patients
starting with the most severe.
1.__________________________
2. __________________________
3. __________________________
18. How many X-rays would it take for a patient to experience any negative effect?
_________ X-rays
19. Please indicate your level of agreement with the following statements:
I feel that CT scans are safe
Strongly disagree1
Disagree2
Neutral3
Agree4
Strongly Agree5
I feel that MRIs are safe
Strongly disagree1
Disagree2
Neutral3
Agree4
Strongly Agree5
I feel that X-rays are safe
Strongly disagree1
Disagree2
Neutral3
Agree4
Strongly Agree5
20. Are you interested in learning more about safety and radiation associated with
medical imaging methods? (Circle one)
Yes1 No2 Maybe3
If yes or maybe, how would you like to receive more information?
(Circle all that apply)
Speaking with a doctor
Reading a pamphlet
Speaking with a nurse
Searching on the internet
Speaking with any health care worker
Other (please describe)______________
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