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Kohl's Cares for Kids Safety Feedback Form
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Safety Feedback Form
How many children do you have in the following age categories:
Under 1 year
8-10 years
1-3 years
11-13 years
4-7 years
14 +
(Under 1 year) Please check all that apply:
My baby always uses an infant seat when riding in a vehicle
My household has cleaners and other poisons that are locked and out of reach
I have a working smoke alarm on every floor of my house
(1-3 years) Please check all that apply:
My children aged 1- 3 years old always use an car seat when riding in a vehicle
My household has cleaners and other poisons that are locked and out of reach
I have a working smoke alarm on every floor of my house
(4-7 years) Please check all that apply:
My children aged 4-7 years old always use a booster seat when riding in a vehicle
My child/children wear bike helmets
My household has cleaners and other poisons that are locked and out of reach
I have a working smoke alarm on every floor of my house
(8+ years) Please check all that apply:
My children aged eight and older wear a seatbelt when riding in a vehicle
My child/children wear bike helmets
My household has cleaners and other poisons that are locked and out of reach
I have a working smoke alarm on every floor of my house
As a result of this website module, how likely are you to engage in the following activities?
Buy a bicycle helmet for your child
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Not likely at all
Unlikely
Maybe
Likely
Very likely
Ensure that your child wears a bicycle helmet
---Select One---
Not likely at all
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Maybe
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Very likely
Install the proper car seat for your child
---Select One---
Not likely at all
Unlikely
Maybe
Likely
Very likely
Tell a friend about what you have learned
---Select One---
Not likely at all
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Maybe
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Request/Look for more information about the topics
---Select One---
Not likely at all
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Maybe
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Lock up household cleaners
---Select One---
Not likely at all
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Maybe
Likely
Very likely
Other (specify)
---Select One---
Not likely at all
Unlikely
Maybe
Likely
Very likely
How did you find out about this website?
Referred by a friend
Heard about it on the radio
Saw a billboard
Read about it in a magazine
Saw a link to it on the Internet
Other (specify):
Recently there have been a series of advertisements about injury prevention in children. Have you:
Heard ads on the radio
Seen billboards
Gone to the Safe Kids Website for Parents
Attended one of the Kohls Tour for Kids Safety Events
Gone to other Safe Kids Events
