Cleft Lip/Palate Informational Packet and Questionnaire
Our Pacific Cleft Prevention Program has developed a brochure and other educational materials to explain the causes of cleft lip and palate and to summarize the prevention studies. We would like to send you the educational package to keep you up to date with important research discoveries and other information.
The packet includes the following:Introduction-to-Questionnaire
- Information about the recent activities in cleft prevention
- “Can we prevent Cleft Lip and Palate?” brochure
- Brochures about the importance of Folic Acid
- General information about Risk of Recurrence
Our program has also developed a short questionnaire for parents of children with cleft and for young adults with cleft. If you are interested in helping us understand more about cleft conditions, including risk reduction and prevention, please complete the form included. Our program is looking for those parents who are still in childbearing age, and for young adults with cleft who wish to have children.
As a thank you for helping us continue our research toward cleft prevention, we will send you the cleft lip and palate informational material when you complete the questionnaire.
Note: If you cannot provide the information necessary to complete the questionnaire, but would still like information on cleft anomalies, please email your name and address to firstname.lastname@example.org.
Thank you for your needed support in helping us develop successful methods for the prevention of cleft lip and palate anomalies.
The questionnaires below are directed particularly towards the biological mothers of children with cleft and young women with cleft.
However, if you are not the mother, but can provide any information concerning the pregnancy and family background, please fill out the questionnaire. Young men with cleft who are interested in having children are also encouraged to participate. Any information will be greatly appreciated.
The information you provide will be used for research purposes only, and will not be given to third parties without your consent. We respect your privacy, and therefore your information will be handled as strictly confidential.
Please click on the link(s) below to download the appropriate forms.
After completion, you may mail or fax it to the address provided on the last page of the questionnaire.
Introduction Page to Questionnaire (PDF)
Questionnaire for Parents of Children with Cleft (PDF)
Questionnaire for Young Adults with Cleft (PDF)
The PDF forms require the use of Adobe Acrobat Reader, which can be downloaded HERE for FREE.
Thank you again for your time and generosity. We greatly appreciate all the information you provide.