Green Housing Study Form Approved
Appendix D1 Screening Questionnaire OMB No. 0920-0906
Household ID #___________
Green Housing Study
Public reporting burden of this collection of information is estimated to average 10 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 (0920-0906).
1. What is your date of birth? _____/_____/_____ (mm/dd/yy)
If mother/ primary caregiver is younger than 18 years, STOP. This household is not eligible.
2. How many children with asthma age 7 to 12 (years) do you have? _______
If answer to Question 2 is Zero (0), then STOP- not eligible.
If answer to Question 2 is ≥ 1 then ask:
How many of your child(ren) with asthma age 7 to 12 (years) meet all of the following criteria?
Doctor or healthcare provider ever said that he/she had asthma.
Child had asthma symptoms in the past 6 months.
Child does not have a medical condition that would make it hard for him/her to participate in the study? (PROBE cystic fibrosis, cerebral palsy)
Child sleeps 7 nights per week at this address, on average.
2.1 Please enter number _______
IIf answer to 2.1 is One (1), then this child is eligible, if more than 1, then the youngest child (willing) is eligible. (Please enter the following information for the eligible child)
2.1.1 What is the child’s date of birth? _____/_____/_____ (mm/dd/yy)
2.1.2 Is this child a girl or boy? (please circle) Girl Boy
IF THIS HOUSEHOLD IS ELIGIBLE, PLEASE COLLECT CONTACT INFORMATION, AND COMPLETE THE CONSENT FORM (and ASSENT FORM IF APPLICABLE)
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Contact Information
Date _____/_____/_____ (mm/dd/yy) Interviewer’s initials(max 3): ____ ____ ____
Study site code: _______________________________________ (if code not available, list housing complex)
NAME OF MOTHER/ PRIMARY CAREGIVER:
_____________________________________________________ _________________
First Last Study ID (mother/ primary caregiver)
NAME OF ENROLLED CHILD (AGE 7-12 YEARS WITH ASTHMA):
_____________________________________________________ _________________
First Last Study ID (Child with asthma 7-12)
What is your relationship to {child’s name}?
Mother (BIRTH)
Mother (ADOPTIVE/ FOSTER)
Mother (STEP)
Father (BIRTH)
Father (ADOPTIVE/ FOSTER)
Father (STEP)
Grandmother
Aunt
Uncle
Grandfather
Other relative
Unrelated
ADDRESS OF HOME:
_____________________________________________________________________________
(Street address) (Apt # or Unit #)
_____________________________________________________________________________
(City) (State) (Zip code)
Longitude ____________ Latitude ______________
Phone number: ( ) _________________________ Phone number: ( ) ________________________
(Circle one*) H – C – W – O H – C – W – O
*H=home; C=cell; W=work; O=other
E-mail address:____________________________________________________________________________
Please provide the names and phone numbers of two people who know how to reach you.
(PROBE: We really need this information ONLY if we have tried to contact you several times to set up your appointments).
Name of alternate contact #1:______________________________________________________
First Last
Relationship (Circle one): Parent Sibling Other relative Friend Co-worker Spouse/Partner Other
Phone number: ( ) ________________________ Phone number: ( ) ______________________
(Circle one*) H – C – W – O H – C – W – O
Name of alternate contact #2:_____________________________________________________
First Last
Relationship (Circle one): Parent Sibling Other relative Friend Co-worker Spouse/Partner Other
Phone number: ( ) ________________________ Phone number: ( ) ______________________
(Circle one*) H – C – W – O H – C – W – O
File Type | application/msword |
File Title | SCREENING QUESTIONNAIRE |
Author | Luis M. Acosta |
Last Modified By | CDC User |
File Modified | 2014-08-06 |
File Created | 2014-08-06 |