Form Approved
OMB No.0920-XXXX
Exp. Date xx/xx/20xx
Parent Questionnaire |
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Participant ID |
_______________________ |
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Name of Assessor |
__________________(free type) |
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Name of Data Clerk |
__________________(free type) |
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Date of assessment |
______ (day – 2 digits) ______ (month – 2 digits) __________ (year – 4 digits) |
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Section A: General Health |
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Excellent Very good Good Fair Poor
_______________ (free type)
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If yes, describe:
If yes, describe:
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No Yes No Yes No Yes No Yes
No Yes
No Yes _______________ (free type) No Yes _______________ (free type)
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No Yes If YES, go to Section B: Breastfeeding
A healthcare provider told us not to I decided to delay some or all of the vaccines I decided my child would not receive any of the vaccines Other, specify _______________ (free type)
_______________ (free type) |
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Section B: Breastfeeding |
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No Yes _____ days (1 digit) OR _____ weeks (1 digit) OR _____ months (2 digits) OR check this box if still breastfeeding _____ days (1 digit) OR _____ weeks (1 digit) OR _____ months (2 digits) OR check this box if child has never been fed formula check this box if still breastfeeding and go to the next question No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes, specify: _______________ (free type)
_____ days (1 digit) OR _____ weeks (1 digit) OR _____ months (2 digits)
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Section C. Sleep |
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Often Sometimes Never Often Sometimes Never Often Sometimes Never Often Sometimes Never Often Sometimes Never |
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Section D. Family Functioning |
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No Yes
No Yes No Yes
Less than 1 hour per week 1-4 hours per week 5-10 hours per week 11 or more hours per week No Yes
No Yes
No Yes
Never Rarely Somewhat often Very often
No Yes No Yes No Yes
< R$500 R$500-R$1,499 R$1,500-R$2,999 R$3,000-R$6,999 > R$7,000 Do not know
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Kotzky, Kim (CDC/ONDIEH/NCBDDD) (CTR) |
File Modified | 0000-00-00 |
File Created | 2021-01-22 |