3 and 9 month follow-up - Chinese

Green Housing Study ID# ______________

6-month follow-up (Child 7-12 with asthma)

House ID# _____________

Green Housing Study

綠色住房研究

3 and 9-month Follow-up Questionnaire

(Children 7-12 with asthma)

第三個和第九個月跟蹤問卷

（7-12嵗由哮喘的小孩）

Public reporting burden of this collection of information is estimated to average 5 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-XXXX)

這個數據收集所造成的回答負擔大約在5分鐘左右，其中包括閲讀指示，搜索現有信息庫，集合和保持所需數據，以及完成並檢查收集的數據。任何單位不能進行或贊助，任何人也沒有必要回答沒有國家管理和經費預算辦公室（OMB）批復編號的數據收集問卷。發送有關回答負擔的評論或者建議到美國疾病控制與方中心(CDC/ATSDR)信息收集審查辦公室：1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXX).

Interviewer Initials _______ Date: ___________

訪問員名字： 日期：

1. Observation point (Circle One):

1. 3-month follow-up (post-remediation)

2. 9-month follow-up (post-remediation)

1．跟蹤時間點：

1. 六個月（翻新后）

2. 十二個月（翻新后

Respiratory illness 呼吸疾病

2. During the past 3 months, did [Child’s name] have any of these conditions?

(If YES, enter number of episodes in space provided)

2．在過去的三個月裏，[小孩名字]出現過一下的症狀嗎？ （出現過的症狀填入次數）

Number 次數

1. Flu or cold Y N DK ______

(Defined by at least 3 of the following: feverish, stuffy/runny nose, cough, sore throat, body aches or tiredness, for more than 24 hours)

2.1流感或者感冒 是 否 不知道

（以至少以下三种症狀為基準：持續24小時以上的發燒， 鼻塞/流鼻涕，咳嗽，喉嚨發炎，身體疼痛或者發軟）

(If YES, then ask)

2.1.1 During these illness episodes, did [Child’s name] asthma get worse? Y N DK

2.1.2 Did [Child’s name] receive Tamiflu® or oseltamivir [o sel TAM i veer] or an inhaled medicine called Relenza® or zanamivir [za NA mi veer] to treat this illness?

Y N DK

2.1.3 Was [Child’s name] prescribed antibiotics? Y N DK

如果是，繼續問：

2.1.1在這些症狀發生時，[小孩名字]的氣喘有加重嗎？ 有 沒有 不知道

2.1.2 [小孩名字]有用Tamiflu，oseltamivir或者另外一種叫Relenza，zanamivir 來治療症狀嗎 ？

有 沒有 不知道

2.1.3 [小孩名字]有用抗生素嗎？ 有 沒有 不知道

2. Pneumonia Y N DK ______

3. Bronchitis Y N DK ______

2.2肺炎 有 沒有 不知道 次數_____

2.3 支氣管炎 有 沒有 不知道 次數_____

Enter frequency by circling one choice

4. Sneezing, runny/stuffed nose (without a cold)

Never Once/Twice Monthly Weekly Daily

5. Wheezing Never Once/Twice Monthly Weekly Daily

6. Cough (without a cold) Never Once/Twice Monthly Weekly Daily

7. Shortness of breath Never Once/Twice Monthly Weekly Daily

2.4 打噴嚏，流鼻涕/鼻塞 （沒有感冒） 從來沒有 一兩次 每月 每週 每日

2.5 喘息 從來沒有 一兩次 每月 每週 每日

2.6 咳嗽（沒有感冒） 從來沒有 一兩次 每月 每週 每日

2.7 氣緊 從來沒有 一兩次 每月 每週 每日

3. During the past 3 months, has [Child’s name] had an episode of asthma or an asthma attack?

Yes No Don’t know

3．在過去的3個月中， [小孩名字]有出現過氣喘或者氣喘症狀嗎？ 有 沒有 不知道

If NO, then SKIP to Contact Information Update

If YES, how many times?

3.1 ______ Number of times

3.2 Did any episode occur in the past 2 weeks? Yes No

如果沒有， 跳到聯係方式更新

如果有，有多少次？

3.1 次數______

3.2 這個症狀在過去的2周裏出現過嗎？ 是 否

4. During the past 3 months, did [Child’s name] have an emergency or urgent care visit because of asthma attack?

Yes No

4．在過去的3個月中， [小孩名字]有因爲氣喘而到過急救中心或者急救部門嗎？ 有 沒有

If NO, Skip to Question # 6 如果沒有，跳到第6題

If YES, did [Child’s name] visit the following?

4.1 Emergency department Y N ____ Number of visits

4.2 Urgent care center Y N ____ Number of visits

4.3 Emergency visit to doctor’s office Y N ____ Number of visits

如果有，[小孩名字]到過以下哪些地方？

4.1 急救科 有 沒有 次數

4.2 急診中心 有 沒有 次數

4.3 緊急到醫生辦公室 有 沒有 次數

5. During the past 3 months, has [Child’s name] stayed in the hospital (NOT considering the emergency department) because asthma?

Yes No

5．在過去的三個月裏，[小孩名字]有因爲哮喘而住院嗎( 不是在急診室過夜)？ 有 沒有

If YES, how many times?

5.1 ____ Maximum number of days at the hospital

5.2 Did [Child’s name] need stay in the ICU? Yes No DK

如果有，有多少次？

5.1 住院最多多少天：

5.2 [小孩名字]住過重症監護室嗎？ 有 沒有

6. During the past 3 months, was [Child’s name] unable to attend school because of asthma?

Yes No

６．在過去的3個月中，[小孩名字]有因爲氣喘而無法上學嗎？ 有 沒有

If YES, then ask: How many days did [Child’s name] miss school?

6.1 _____ Number of days [Child’s name] missed school

[Include only days school was in session.]

6.2 Did this occur in the past 2 weeks? Yes No

If YES, how many times?

6.2.1_____ Number of days [Child’s name] missed school

[Include only days school was in session.]

如果有，繼續問：[小孩名字]一共缺席多少天？

６.1______[小孩名字]缺席的天數 （只包括學校開的日子）

６．２　[小孩名字]在過去的2個星期裏缺席了嗎？ 有 沒有

7. During the past 3 months, were YOU unable to attend work or carry out your usual activities because of [Child’s name] asthma?

Yes No

７．在過去的3個月裏，你有因爲小孩的氣喘而無法上班或者進行日常的活動嗎？ 有 沒有

If YES, then ask

7.1 _____ Total number of days (use your best guess)

7.1.1 _____ Of these, how many work days did you miss?

如果有，繼續問：

7.1 ______縂天數 （最好的估計）

7.1.1 其中有________天你無法上班

7.2 Did this occur in the past 2 weeks? Yes No

7.2 你在過去的2周裏有因爲孩子的氣喘而無法上班嗎？ 有 沒有

If YES, then ask

7.2.1_____ Number of days you missed work (if applicable)

7.2.2_____ Number of days you missed other activities

如果有，繼續問

7.2.1 有_____天你無法上班（如果適用）

7.2.2．有_____天你無法進行其他活動

8. In the past 3 months, did [Child’s name] wake up at night because of asthma?

Yes No

8．在過去的3 個月裏，[小孩名字]有因爲氣喘而半夜突然醒來嗎？ 有 沒有

If YES, then ask

8.1 ______ Number of nights (use your best guess)

8.2 Did this occur in the past 2 weeks? Yes No

If YES, then ask

8.2.1 ______ Number of nights

如果有，繼續問：

8.1 ______晚上

8.2 這個/些再過去的2周裏出現過嗎？ 有 沒有

如果有，再問：

8.2.1 ________晚上

Contact Information

Telephone numbers: Same New

Home ( ) ______________ ( ) ( )

Work ( ) ______________ ( ) ( )

Cellular ( ) ______________ ( ) ( )

Email address __________________ ( ) ( )

聯係方式

電話號碼： 與以前一樣 更新

家裏

工作

手機

電子郵件

Alternate Contacts

Telephone numbers: Same New Relationship to respondent

Home ( ) ______________ ( ) ( ) ____________________

Work ( ) ______________ ( ) ( ) ____________________

Cellular ( ) ______________ ( ) ( ) ____________________

Email address __________________ ( ) ( ) ____________________

其他聯係方式

電話號碼 與以前一樣 更新 跟參與人的關係

家裏

工作

手機

電子郵件

Remind subject to collect nasal and throat swabs and call study coordinator for sample pick up.

Also important to remind subject about keeping an illness log with eventful health outcomes like visit to doctor, hospitalization etc. Also, ask to collect the completed logs.

提醒參與人進行對小孩鼻子和喉嚨的擦拭和聯係研究協調員來提取樣本。

同時也提醒參與人保持一個生病日誌，包括看醫生，住院等情況。還有收取完成了的日誌。

1

DK = Don’t know R = Refused NA = Not applicable