CASE CONTROL Form Approved
OMB No.0920-1013
Exp. Date 04/30/2017
Patient ID:__________________________
State ID:__________________________
REFERENCE Date _____/_____/______
Attachment G: Community-associated Clostridium difficile Infection (CDI) Risk Factor Study Pediatric Case and Control Interview
Section 1: Identifiers***Cases AND Controls*******
1. CASE CONTROL
2. Study ID: __________________________________
3. If Control, Reference date: _____/_____/______
(mm/dd/yyyy)
2 weeks before _____/_____/______
4 weeks before _____/_____/______
12 weeks before _____/_____/______
4. Age: Years Months
5. Sex: Male Female
Section 2: Illness Questions- ****CASES ONLY ****CONTROLS SKIP TO SECTION 3, Q.11****
Now I will ask you questions about your child’s illness.
6. Do [you] remember when your child’s diarrhea began around (positive specimen date ___/_____/______)?
Yes 1 (If Yes –fill in date diarrhea began and use as reference date.)
No 2 (fill in date of specimen collection and use as reference date.)
Don’t know/Not sure 7 (fill in date of specimen collection and use as reference date.)
Refused 9 (fill in date of specimen collection and use as reference date.)
REFERENCE DATE: _____/_____/______
(mm/dd/yyyy)
2 week before _____/_____/______
4 weeks before _____/_____/______
12 weeks before _____/_____/______
7. How many days did your child’s diarrhea last around the time of (reference date ____/_____/______)?
Don’t know/Not sure 7
Refused 9
7A. On the worst day of your child’s diarrhea around the time of (reference date ____/_____/______), what was the approximate number of stools your child had in a 24-hour period?
≥3-<5 stools 1
5-10 stools 2
>10 stools 3
Don’t know/Not sure 7
Refused 9
8. Did your child have any of the following symptoms associated with [his/ her] C. difficile illness around the time of (reference date ____/_____/______)?
[READ LIST] Yes No DK/NS Refused
Bloody stools 1 2 7 9
Fever 1 2 7 9
Nausea 1 2 7 9
Vomiting 1 2 7 9
Abdominal pain 1 2 7 9
Other 1 2
Specify:_______________________________________________________________
9. Was your child hospitalized overnight for [his/ her] C. difficile illness around the time of (reference date ____/_____/______)?
9A. If yes, where: _____________________________
(name of hospital will not be transmitted to CDC)
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
10. At the time of your child’s C. difficile diagnosis around the time of (reference date ____/_____/______), was your child told by a doctor or healthcare provider that [she/ he] had any other stomach [enteric, gastrointestinal] infection?
Yes 1
No 2 (Go to Q.11)
Don’t know/Not sure 7 (Go to Q.11)
Refused 9 (Go to Q.11)
10A. If yes, what was the name of the infection?
[Read list if necessary] Yes No DK/NS Refused
Campylobacter 1 2 7 9
E. coli 1 2 7 9
Listeria 1 2 7 9
Salmonella 1 2 7 9
Shigella 1 2 7 9
Vibrio 1 2 7 9
Yersinia 1 2 7 9
Cryptosporidium 1 2 7 9
Giardia 1 2 7 9
Rotavirus 1 2 7 9
Norovirus 1 2 7 9
Other 1 2
Specify:_____________________________________________________________________
Section 3: Healthcare contacts- Cases and Controls
Now I will ask you questions about your child’s healthcare contacts between 12 weeks before [Reference Date_____/_____/______] to [Reference Date_____/_____/______].
11. Did your child receive care in any doctor’s office, dental office, hospital, or any other medical facility in the 12 weeks before [REFERENCE DATE ____/_____/_____]?
Yes 1
No 2 (Go to Q.12)
Don’t know/Not sure 7 (Go to Q. 12)
Refused 9 (Go to Q.12)
11A. I will now ask you about the types of places your child visited for [his / her] healthcare in that time period and when [he / she] made the visit. Did your child visit any of the following places?
[READ LIST] |
YES=1 |
NO=2 |
DN/NS=7 |
Refuse=9 |
How many weeks prior to [Reference Date_____/_____/______] did your child visit this place? |
||
|
|
|
|
|
2 weeks |
4 weeks |
12 weeks |
Outpatient Procedure Center |
|
|
|
|
|
|
|
Ambulatory /Outpatient surgery center |
|
|
|
|
|
|
|
Dental office |
|
|
|
|
|
|
|
Doctor’s office |
|
|
|
|
|
|
|
Emergency department/room |
|
|
|
|
|
|
|
Hemodialysis |
|
|
|
|
|
|
|
Hospital |
|
|
|
|
|
|
|
Outpatient lab |
|
|
|
|
|
|
|
Physical therapy center |
|
|
|
|
|
|
|
Urgent care |
|
|
|
|
|
|
|
Other (Specify)
|
|
|
|
|
|
|
|
IF NO TO ALL OPTIONS IN Q.11A then SKIP to Q.12
11B. during those visits in the 12 weeks before [Reference Date_____/_____/______] did your child have any of the following procedures performed?
*****If Subject answered YES to dental visits only in 11A then only ask about last two items (oral surgery and dental cleaning)*****
[READ LIST] |
YES=1 |
NO=2 |
DN/NS=7 |
Refuse=9 |
How many weeks prior to [Reference Date_____/_____/______] did this procedure happen? |
||
|
|
|
|
|
2 weeks |
4 weeks |
12 weeks |
Upper Endoscopy (Did the doctors pass a tube through your mouth or nose into your stomach?) |
|
|
|
|
|
|
|
Colonoscopy or Sigmoidoscopy (Did the doctors pass a tube into your rectum to look into your colon/bowel?) |
|
|
|
|
|
|
|
X-ray that required GI Prep (Did you have an X-ray performed where you had to swallow something first?) |
|
|
|
|
|
|
|
Chemotherapy |
|
|
|
|
|
|
|
Surgery in an operating room If yes, Specify type:
|
|
|
|
|
|
|
|
Other Medical Procedure:
|
|
|
|
|
|
|
|
Oral Surgery |
|
|
|
|
|
|
|
Dental Cleaning |
|
|
|
|
|
|
|
12. Did your child visit a person in or go with anyone to a doctor’s office, dental office, hospital, nursing home, or any other medical facility in the 12 weeks before [Reference Date_____/_____/______]?
Yes 1
No 2 (Go to Q.13)
Don’t know/Not sure 7 (Go to Q.13)
Refused 9 (Go to Q.13)
12A. What type of facility did your child visit or go withsomeone to in the 12 weeks before [Reference Date ____/_____/_____]?
[READ LIST] |
YES=1 |
NO=2 |
DN/NS=7 |
Refuse=9 |
How many weeks prior to [Reference Date_____/_____/______] did your child visit this place? |
||
|
|
|
|
|
2 weeks |
4 weeks |
12 weeks |
Outpatient procedure center |
|
|
|
|
|
|
|
Ambulatory / Outpatient surgery center |
|
|
|
|
|
|
|
Dental office |
|
|
|
|
|
|
|
Doctor’s office |
|
|
|
|
|
|
|
Emergency department/room |
|
|
|
|
|
|
|
Hemodialysis |
|
|
|
|
|
|
|
Hospital |
|
|
|
|
|
|
|
Long term care/ skilled nursing facility |
|
|
|
|
|
|
|
Outpatient lab |
|
|
|
|
|
|
|
Physical therapy center |
|
|
|
|
|
|
|
Urgent care |
|
|
|
|
|
|
|
Other (Specify):
|
|
|
|
|
|
|
|
Section 4: Household contacts
The next few questions are about your child and persons who lived with your child during the 12 weeks before [Reference Date_____/_____/______].
13. Excluding your child, how many people lived in your child’s household during that time?
13A. What were the ages of the people living in your child’s household, not including your child?
[List number of people in each group]
Ages <1 1 to 3 4 to 10 11 to 17 18 to 34 35 to 59 60+
14. Did any household member excluding your child wear diapers around the time of (reference date ____/_____/______)? (Including adults in diapers)
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
15. Did any household members excluding your child attend a group childcare setting, daycare, or adult daycare around the time of (reference date ____/_____/______)? We consider daycare to be any place inside or outside your home where a household member spends at least 4 hours per week under an adult’s care with at least two other people who do not live with your child.
Yes 1
No 2 (Go to Q.16)
Don’t know/Not sure 7 (Go to Q.16)
Refused 9 (Go to Q.16)
15A
. If yes, what type(s) of daycare setting was it?[Read description of setting types if necessary
Home……………………………………1
Center…………………………………..2
Members attend both types of daycare………….3
Don’t know / Not Sure………………..7
Refused……………………………….9
]
Home
– care is provided in someone’s home typically by one
person Center-
care is provided typically in a commercial building with many
providers and rooms
16. In the 12 weeks before [Reference Date_____/_____/______], did any household member stay overnight in a hospital?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
17. In the 12 weeks before [Reference Date_____/_____/______], did any household member stay overnight in a nursing home?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
18. In the 12 weeks before [Reference Date_____/_____/______], did anyone else in your child’s household have diarrhea?
Yes 1
No 2 (Go to Q.19)
Don’t know/Not sure 7 (Go to Q.19)
Refused 9 (Go to Q.19)
18A. Was this person diagnosed with C. difficile?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
19. Did any of your child’s household members work at or volunteer, in any capacity, at a hospital, other medical facility, or in any facility where patient care is provided in the 12 weeks before [Reference Date____/_____/_____]? Volunteering can mean doing anything that requires you to enter a healthcare facility. Examples include: playing a musical instrument in the lobby, helping to direct patients to the correct area.
Yes 1
No 2 (Go to Q.20)
Don’t know/Not sure 7 (Go to Q.20)
Refused 9 (Go to Q.20)
19A. If yes, what type of healthcare setting?
(READ LIST) Yes No DK/NS Refused
Hospital 1 2 7 9
Emergency department/room 1 2 7 9
Doctor’s office 1 2 7 9
Dentist 1 2 7 9
Long term care/skilled nursing facility 1 2 7 9
Hemodialysis facility 1 2 7 9
Other facility 1 2
Specify:_____________________________________________________________________
19B. Did their job involve direct physical contact with patients? For example touching the patient to help her get out of a chair.
Yes 1
No 2 (Go to Q.20)
Don’t know/Not sure 7 (Go to Q.20)
Refused 9 (Go to Q.20)
19B1. If yes, what was their main job? _____________________________________________________
19C2. Job Code- (Fill in job code after interview is finished)
20. Did your child attend a group childcare or daycare in the 12 weeks before [Reference Date____/_____/_____]? We consider daycare to be any place inside or outside your home where your child spends at least 4 hours per week under an adult’s care with at least two children who do not live with you.
Yes 1
No 2 (Go to Q.21)
Don’t know/Not sure 7 (Go to Q.21)
Refused 9 (Go to Q.21)
20A. If yes, what type of childcare setting? [Read list if necessary]
Home–care is provided in someone’s home typically by one person 1
Center-care is provided typically in a commercial building with many providers and rooms 2
Other 4
Specify: __________________________________________________
Don’t know/Not sure 7
Refused 9
Section 5: Diet Exposures
I’d like to change direction now and ask you about the foods your child generally eats in a given week and the kind of water your child drinks.
21. In a current typical week, not in the pat timeframe we have talked about, how frequently does your child consume the following foods?
[READ LIST] |
Often |
Sometimes |
Rarely |
Never |
DK/NS |
Refused |
|
>5/week |
2-5 /week |
<2/ week |
Never |
|
|
Eggs |
1 |
2 |
3 |
4 |
7 |
9 |
Dairy (milk, yogurt) |
1 |
2 |
3 |
4 |
7 |
9 |
Fresh-cut raw vegetables |
1 |
2 |
3 |
4 |
7 |
9 |
Plant-based protein (tofu, tempeh, seitan) |
1 |
2 |
3 |
4 |
7 |
9 |
Red Meat (beef, lamb, other game meat) |
1 |
2 |
3 |
4 |
7 |
9 |
Poultry (chicken, turkey) |
1 |
2 |
3 |
4 |
7 |
9 |
Seafood (fish, shellfish) |
1 |
2 |
3 |
4 |
7 |
9 |
22. Did your child receive food / formula through a feeding tube called a G-tube or J-tube in the 12 weeks before [Reference Date_____/_____/______]?
Yes 1
No 2
Don’t know/Not sure 7
Refused 9
23. Which one of the following is the source of tap water in the home your child was living in around the time of (reference date ____/_____/______) (select only one):
water utility private well spring unknown other
Name of the water utility, if known ______________________________________
If other, specify type and location ______________________________________
23A. At that home, what type of unboiled water did your child most often use for drinking (chose only one)?
______Tap water not treated in the home
______Tap water treated in the home (for example, filtered, UV light, distilled, or whole house point-of-entry device)
______Commercially bottled water
______Other (specify): ________________________
24. During the first 6-months of your child’s life, would you say: [READ CHOICES]
Almost 100% of feedings were breast milk with no or very little formula…………1
Most feedings (about 75%) were breast milk and the rest were formula………...2
About half (or 50%) of feedings were breast milk and half were formula………...3
Most feedings (about 75%) were formula and the rest were breast milk…………4
Almost 100% of feedings were formula with no or very little breast milk…………5
Don’t know/Not sure…………………………………………………………………….7
Refused …………………………………………….9
Section 6: Medical History
The next set of questions is about medications your child may have been taking in the 12 weeks before [Reference Date_____/_____/______]. Medicine bottles or records may help you remember about specific medications. Would you like to gather this information before we go on?
25. Did your child take any antibiotics by mouth or in an I.V. (in his/ her vein) in the 12 weeks before [Reference Date_____/_____/______]?
Yes 1
No 2 (Go to Q.27)
Don’t know/Not sure 7 (Go to Q. 27)
Refused 9 (Go to Q.27)
26. Why did your child take these antibiotics?
Note: Subjects may indicate more than one reason (For example, if more than one course of antibiotics was taken for different illnesses or if one antibiotic was taken for and ear infection and a pneumonia)
[DO NOT READ LIST] |
Yes |
No |
Bronchitis/ pneumonia |
1 |
2 |
Dental cleaning |
1 |
2 |
Ear, sinus, upper respiratory infection |
1 |
2 |
Eye infection |
1 |
2 |
Oral surgery |
1 |
2 |
Skin or soft tissue infection (abscess or cellulitis) |
1 |
2 |
Surgery |
1 |
2 |
Urinary tract infection |
1 |
2 |
Urinary tract infection prophylaxis |
1 |
2 |
DK/NS |
7 |
7 |
Refused |
9 |
9 |
Other |
1 |
2 |
Specify: |
26A. Which antibiotic(s) did your child take in the 12 weeks before [Reference Date_____/_____/______]? [DO NOT READ LIST]
[DO NOT READ LIST]
|
|
If yes, how many weeks prior to [Reference Date_____/_____/______] did your child take this antibiotic? |
||
|
YES |
2 weeks |
4 weeks |
12 weeks |
Amoxicillin |
1 |
|
|
|
Amoxicillin/Clavulanate or Augmentin |
1 |
|
|
|
Ampicillin |
1 |
|
|
|
Azithromycin |
1 |
|
|
|
Cefaclor |
1 |
|
|
|
Cefadroxil |
1 |
|
|
|
Cefdinir |
1 |
|
|
|
Cefixime |
1 |
|
|
|
Cefuroxime |
1 |
|
|
|
Cefprozil |
1 |
|
|
|
Cephalexin or keflex |
1 |
|
|
|
Cephradine |
1 |
|
|
|
Ciprofloxacin or Cipro |
1 |
|
|
|
Clarithromycin |
1 |
|
|
|
Clindamycin |
1 |
|
|
|
Dapsone |
1 |
|
|
|
Doxycycline |
1 |
|
|
|
Erythromycin |
1 |
|
|
|
Erythromycin/sulfa |
1 |
|
|
|
Fosfomycin |
1 |
|
|
|
Levofloxacin or levaquin |
1 |
|
|
|
Metronidazole or flagyl |
1 |
|
|
|
Norfloxacin or Norflox |
1 |
|
|
|
Ofloxacin or Oflox |
1 |
|
|
|
Penicillin or Pen VK |
1 |
|
|
|
Tetracycline |
1 |
|
|
|
Trimethoprim/Sulfa or Bactrim, Septra |
1 |
|
|
|
Vancomycin |
1 |
|
|
|
Other antibiotic 1 |
1 |
|
|
|
Specify other antibiotic 1 |
1 |
|
|
|
Other antibiotic 2 |
1 |
|
|
|
Specify other antibiotic 2 |
1 |
|
|
|
Don’t know/Not sure |
7 |
|
|
|
Refused |
9 |
|
|
|
27. Did your child use any antibiotic eye drops or ointment in the 12 weeks before [Reference Date_____/_____/______]?
Yes 1
No 2 (Go to Q.28)
Don’t know/Not sure 7 (Go to Q.28)
Refused 9 (Go to Q.28)
27A. If yes, what was the name of the drop (read list if necessary)?
Polytrim (Polymyxin sulfate / TMP)…….1
Ciloxan (Ciprofloxacin)…………………..2
Ocuflox (Ofloxacin)……………………….3
Vigamox, Moxeza (Moxifloxacin) ……..4
Other……………………………………….9
Specify: ________________________
28. In the 12 weeks before [Reference Date_____/_____/______], did your child regularly take any acid-reducing medications to treat excessive stomach acid, heartburn, or gastroesophageal reflux disease (GERD)? We define regular use as use of the product at least 3 days per week. Such medications might include Prevacid, Tums, Maalox, Mylanta, Tagamet, Zantac, Prilosec, or Nexium.
Yes 1
No 2 (Go to Q.29)
Don’t know/Not sure 7 (Go to Q.29)
Refused 9 (Go to Q.29)
28A. If Yes, please specify which medicine your child regularly took in those 12 weeks.
[DO NOT READ LIST] |
YES=1 |
NO=2 |
How many weeks prior to [Reference Date_____/_____/______ ] did your child take this medication? |
||
|
|
|
2 weeks |
4 weeks |
12 weeks |
Aciphex/rabeprazole |
1 |
2 |
|
|
|
Alka-Seltzer |
1 |
2 |
|
|
|
Maalox |
1 |
2 |
|
|
|
Mylanta |
1 |
2 |
|
|
|
Nexium/esomeprazole |
1 |
2 |
|
|
|
Pepcid/famotidine |
1 |
2 |
|
|
|
Prevacid/lansoprazole |
1 |
2 |
|
|
|
Prilosec/omeprazole |
1 |
2 |
|
|
|
Protonix/pantoprazole |
1 |
2 |
|
|
|
Rolaids |
1 |
2 |
|
|
|
Tums |
1 |
2 |
|
|
|
Tagamet/cimetidine |
1 |
2 |
|
|
|
Zantac/ranitidine |
1 |
2 |
|
|
|
Other (Specify):
|
1 |
2 |
|
|
|
Don’t know/Not sure |
7 |
7 |
|
|
|
Refuse |
9 |
9 |
|
|
|
If yes, in the
2 weeks before
I am now going to ask about medications that are given for many reasons. These reasons includethings like chronic pain, depression, anxiety, and to help sleep. Examples of these medications include: Prozac, Celexa, Remeron, Paxil, and Trazadone.
29. In the 12 weeks before [Reference Date_____/_____/______], did your child regularly take any such medications? We define regular use as use of the product at least 3 days per week.
Yes 1
No 2 (Go to Q.30)
Don’t know/Not sure 7 (Go to Q.30)
Refused 9 (Go to Q.30)
29A. If Yes, please specify which medicine your child regularly took in the 12 weeks before [Reference Date_____/_____/______]
[DO NOT READ LIST] |
|
How many weeks prior to [Reference Date_____/_____/______] did your child take this medication? |
|||
|
YES |
NO |
2 weeks |
4 weeks |
12 weeks |
Amitriptyline |
1 |
2 |
|
|
|
Anafranil (Clomipramine) |
1 |
2 |
|
|
|
Asendin (Amoxapine) |
1 |
2 |
|
|
|
Celexa, Cipramil (Citalopram) |
1 |
2 |
|
|
|
Cymbalta (Duloxetine) |
1 |
2 |
|
|
|
Effexor (Venlafaxine) |
1 |
2 |
|
|
|
Eldepryl, Emsam, Zelapar (Selegiline) |
1 |
2 |
|
|
|
Escitalopram |
1 |
2 |
|
|
|
Limbitrol (Chlordiazepoxide/Amitriptyline) |
1 |
2 |
|
|
|
Ludiomil,(Maprotiline) |
1 |
2 |
|
|
|
Luvox (Fluvoxamine) |
1 |
2 |
|
|
|
Marplan (Isocarboxazid) |
1 |
2 |
|
|
|
Nardil, Nardelzine (Phenelzine sulfate) |
1 |
2 |
|
|
|
Norpramin (Desipramine) |
1 |
2 |
|
|
|
Nortriptyline |
1 |
2 |
|
|
|
Parnate,(Tranylcypromine) |
1 |
2 |
|
|
|
Paxil (Paroxetine) |
1 |
2 |
|
|
|
Pristiq (Desvenlafaxine) |
1 |
2 |
|
|
|
Prozac, Sarafem, Fontex (Fluoxetine) |
1 |
2 |
|
|
|
Remeron, Avanza, Zispin (Mirtazapine) |
1 |
2 |
|
|
|
Savella, (Milnacipran) |
1 |
2 |
|
|
|
Serzone, (Nefazodone) |
1 |
2 |
|
|
|
Silenor, Prudoxin, Zonalon (Doxepin) |
1 |
2 |
|
|
|
Surmontil (Trimipramine) |
1 |
2 |
|
|
|
Symbyax (Olanzapine/fluoxetine) |
1 |
2 |
|
|
|
Tofranil, (Imipramine) |
1 |
2 |
|
|
|
Trazadone |
1 |
2 |
|
|
|
Triptafen (amitriptyline/perphenazine) |
1 |
2 |
|
|
|
Viibryd (Vilazodone) |
1 |
2 |
|
|
|
Vivactil, (Protriptyline) |
1 |
2 |
|
|
|
Wellbutrin, Zyban (Bupropion) |
1 |
2 |
|
|
|
Zoloft, Lustral (Sertraline) |
1 |
2 |
|
|
|
Other:
|
|
|
|
|
|
Don’t know/Not Sure |
7 |
7 |
|
|
|
Refuse |
9 |
9 |
|
|
|
Now I am going to ask you about medical conditions your child may have had.
30. Prior to [Reference Date_____/_____/______], were you ever told by a medical provider that your child had any of the following medical conditions? [READ LIST – including information in parentheses]
READ LIST |
Yes |
No |
DK/NS |
Refused |
Congenital heart disease Specify: |
|
|
|
|
Diabetes |
|
|
|
|
Chronic renal (kidney) failure |
|
|
|
|
If yes, is your child on dialysis or awaiting dialysis? |
|
|
|
|
Chronic lung disease (BPD) |
|
|
|
|
Asthma |
|
|
|
|
Cystic fibrosis |
|
|
|
|
Organ transplant |
|
|
|
|
Bone marrow transplant |
|
|
|
|
Leukemia or lymphoma |
|
|
|
|
Sickle cell disease (not sickle cell trait) |
|
|
|
|
Cancer (e.g. bone, liver, brain) |
|
|
|
|
Short gut disease (bowel/ intestinal insufficiency) |
|
|
|
|
Depression |
|
|
|
|
Born by C-section? |
|
|
|
|
Stay in the NICU at birth? |
|
|
|
|
If yes, was your child premature? How many weeks premature? |
|
|
|
|
If yes, how many weeks in the NICU? |
|
|
|
|
Other illnesses: |
|
|
|
|
31. What are your child’s most recent height or length and weight?
Height/ length: Ft in (or cm)
Weight: lbs (or Kg)
Don’t know/ Not Sure….7 [Prompt by saying: Sometimes children’s doctors give parents records or charts with their child’s weight and height. If you have these I can wait while you get them]
Refused ………………..9
Section 8: Demographics
Now I would like to ask you a few final questions.
32. Do you consider your child to be? [Read responses 1 & 2]
( ) 1 Hispanic or Latino
( ) 2 Not Hispanic or Latino
( ) 7 Don’t Know/Not Sure (DO NOT READ)
( ) 9 Refused (DO NOT READ)
( ) 10. Other racial category (DO NOT READ)
33. I am going to read a list of racial categories. Which one or more of the following do you consider your child to be…? [Read responses 1-5 and allow respondent to select one or more]
( ) 1 White/Caucasian
( ) 2 Black or African-American
( ) 3 American Indian or Alaska Native
( ) 4 Native Hawaiian or Other Pacific Islander
( ) 5 Asian
( ) 7 Don’t Know/Not Sure (DO NOT READ)
( ) 9 Refused (DO NOT READ)
( ) 10. Other racial category (DO NOT READ)
34. What was your child’s main type of health care coverage during 12 weeks before [Reference Date_____/_____/_____] and [Reference Date_____/_____/______]? I’m going to read all the choices.
Private insurance, such as an HMO, PPO or a managed care plan 1
Public insurance, such as Medicaid, Medicare or state assistance program 2
A combination of private and public insurance 3
No health insurance 4
[DO NOT READ]: Other [specify] _________________________ 5
Don’t know or not sure 7
Refused 9
I have just a few more questions about the parent or guardian who cares for [child’s name] most often.
35. What is the highest grade or year of school that any of the household members completed? Please answer this question based on the highest level of education in your household
___1 Never attended school or kindergarten only |
___2 Elementary or middle school; 1st-8th grade |
___3 Some high school; 9th-11th grade |
___4 High school graduate; 12th grade or GED |
___5 College or technical school for 1-3 years |
___6 College for 4 years, with or without a degree |
___9 Refused |
36. In your child’s home, what is the household income from all sources? Read each response in order until respondent agrees.
___1 Less than $15,000 |
___5 Less than $70,000 |
___2 Less than $25,000 |
___6 $70,000 or more |
___3 Less than $35,000 |
___7 Don’t know or not sure |
___4 Less than $50,000 |
___9 Refused
|
That was my last interview question. Thank you very much for your time and participation!
37. Comments: _____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
38. Interview Completed? Yes No
39. Date of interview: ____/____/______
(mm/dd/yyyy)
40. Interviewer initials: ______________
Health Interview Appendix—Job Codes
OFFICE OF MANAGEMENT AND BUDGET - 1998 Standard Occupational Classification
29-0000 Healthcare Practitioners and Technical Occupations
29-1000 Health Diagnosing and Treating Practitioners
29-1010 Chiropractors
29-1020 Dentists
29-1021 Dentists, General
29-1022 Oral and Maxillofacial Surgeons
29-1023 Orthodontists
29-1024 Prosthodontists
29-1029 Dentists, All Other Specialists
29-1030 Dietitians and Nutritionists
29-1040 Optometrists
29-1050 Pharmacists
29-1060 Physicians and Surgeons
29-1061 Anesthesiologists
29-1062 Family and General Practitioners
29-1063 Internists, General
29-1064 Obstetricians and Gynecologists
29-1065 Pediatricians, General
29-1066 Psychiatrists
29-1067 Surgeons
29-1069 Physicians and Surgeons, All Other
29-1070 Physician Assistants
29-1080 Podiatrists
29-1110 Registered Nurses
29-1120 Therapists
29-1121 Audiologists
29-1122 Occupational Therapists
29-1123 Physical Therapists
29-1124 Radiation Therapists
29-1125 Recreational Therapists
29-1126 Respiratory Therapists
29-1127 Speech-Language Pathologists
29-1129 Therapists, All Other
29-1130 Veterinarians
29-1190 Miscellaneous Health Diagnosing and Treating Practitioners
29-1199 Health Diagnosing and Treating Practitioners, All Other
29-2000 Health Technologists and Technicians
29-2010 Clinical Laboratory Technologists and Technicians
29-2011 Medical and Clinical Laboratory Technologists
29-2012 Medical and Clinical Laboratory Technicians
29-2020 Dental Hygienists
29-2030 Diagnostic Related Technologists and Technicians
29-2031 Cardiovascular Technologists and Technicians
29-2032 Diagnostic Medical Sonographers
29-2033 Nuclear Medicine Technologists
29-2034 Radiologic Technologists and Technicians
29-2040 Emergency Medical Technicians and Paramedics
29-2050 Health Diagnosing and Treating Practitioner Support Technicians
29-2051 Dietetic Technicians
29-2052 Pharmacy Technicians
29-2053 Psychiatric Technicians
29-2054 Respiratory Therapy Technicians
29-2055 Surgical Technologists
29-2056 Veterinary Technologists and Technicians
29-2060 Licensed Practical and Licensed Vocational Nurses
29-2070 Medical Records and Health Information Technicians
29-2080 Opticians, Dispensing
29-2090 Miscellaneous Health Technologists and Technicians
29-2091 Orthotists and Prosthetists
29-2099 Health Technologists and Technicians, All Other
29-9000 Other Healthcare Practitioners and Technical Occupations
29-9010 Occupational Health and Safety Specialists and Technicians
29-9011 Occupational Health and Safety Specialists
29-9012 Occupational Health and Safety Technicians
29-9090 Miscellaneous Health Practitioners and Technical Workers
29-9091 Athletic Trainers
29-9099 Healthcare Practitioners and Technical Workers, All Other
31-0000 Healthcare Support Occupations
31-1000 Nursing, Psychiatric, and Home Health Aides
31-1010 Nursing, Psychiatric, and Home Health Aides
31-1011 Home Health Aides
31-1012 Nursing Aides, Orderlies, and Attendants
31-1013 Psychiatric Aides
31-2000 Occupational and Physical Therapist Assistants and Aides
31-2010 Occupational Therapist Assistants and Aides
31-2011 Occupational Therapist Assistants
31-2012 Occupational Therapist Aides
31-2020 Physical Therapist Assistants and Aides
31-2021 Physical Therapist Assistants
31-2022 Physical Therapist Aides
31-9000 Other Healthcare Support Occupations
31-9010 Massage Therapists
31-9090 Miscellaneous Healthcare Support Occupations
31-9091 Dental Assistants
31-9092 Medical Assistants
31-9093 Medical Equipment Preparers
31-9094 Medical Transcriptionists
31-9095 Pharmacy Aides
31-9096 Veterinary Assistants and Laboratory Animal Caretakers
31-9099 Healthcare Support Workers, All Other
Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1013).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | CDC User |
File Modified | 0000-00-00 |
File Created | 2021-01-27 |