CHILD’S STUDY ID: __________ -___-______________________ Form Approved
PARENT’S STUDY ID: __________ -___-______________________ OMB No. 0920-1190
Date: __ __/__ __ __ /__ __ __ __ Exp. Date 02/28/2021
D D M M M Y Y Y Y
Staff Administered: ___________________________
PARENT-CHILD Follow-Up Questionnaire
Age (in months) of child at study visit, approximate (circle): 9 12 18 24 36 48
First we have a few questions about you and your household.
What is your relationship to this child?
0 Mother
1 Father
2 Legal guardian (Specify relationship:______________________________________)
Does your child live with you?
1 Yes 0 No 77 Don’t know 88 Refused
Including you and your child, how many adults and children live in the same household as your child?
______ adults (18+ years) ______ children (<18 years) 77 Don’t know 88 Refused
If, according to question #3, there are no other children in the household, go to question #5.
How old are each of the other children that live in the household with your child, not including your child enrolled in ZEN?
Age of other child (1):________ years 77 Don’t know 88 Refused
Age of other child (2):________ years 77 Don’t know 88 Refused
Age of other child (3):________ years 77 Don’t know 88 Refused
Age of other child (4):________ years 77 Don’t know 88 Refused
Age of other child (5):________ years 77 Don’t know 88 Refused
Age of other child (6):________ years 77 Don’t know 88 Refused
Age of other child (7):________ years 77 Don’t know 88 Refused
Age of other child (8):________ years 77 Don’t know 88 Refused
Age of other child (9):________ years 77 Don’t know 88 Refused
Age of other child (10):________ years 77 Don’t know 88 Refused
Now we want to learn a bit more about who helps provide care for your child.
First, tell me about how often you have provided care for your child since your last study visit.
How many days per week do you provide care for your child?
_______ days per week 88 Refused
On days when you provide care for your child, how many hours per day?
_______ hours per day 88 Refused
Has someone helped you to provide care for your child on a regular basis since your last study visit?
1 Yes 0 No 88 Refused
If question #5c is “No” then go to question #7.
Please think about the three people (such as family members or professional caregivers) who have helped provide care for your child on a regular basis most often since your last study visit, other than you. I will ask you some questions about each of these people.
Person (1) |
|
6a. For the first person you’ve thought of, what is this person’s relationship to your child? I will read you a list of options and please select the best one. |
0 Child’s mother 1 Child’s father 2 Non-parental partner of your child’s mother/ father 3 Child’s grandparent 4 Child’s relative under age 18 (including a sibling younger than 18) 5 Other adult relative (including a sibling 18 or older) 6 Friend or neighbor 7 Unrelated adult (including a professional at a child care center) 8 Other 88 Refused 66 Not applicable – I do not have another person who cares for my child (If not applicable, skip to question #7).
|
|
If other, specify:______________________________ |
6b. Does this person help care for your child in the following locations? |
|
In the child’s home |
1 Yes 0 No 88 Refused |
In someone else’s home |
1 Yes 0 No 88 Refused |
In a childcare center/nursey |
1 Yes 0 No 88 Refused |
Other |
1 Yes 0 No 88 Refused |
|
If other, specify:______________________________ |
6c. How many days per week does this person help care for your child? |
_______ days per week 88 Refused |
6d. On days when this person helps care for your child, how many hours per day? |
_______ hours per day 88 Refused |
6e. On average, how many additional children does this person care for at the same time as your child? |
________ children 88 Refused |
6f. On average, how many additional people also provide care for your child alongside this person? |
________ people 88 Refused |
Person (2) |
|
6g. For the second person you’ve thought of, what is this person’s relationship to your child? I will read you a list of options and please select the best one. |
0 Child’s mother 1 Child’s father 2 Non-parental partner of your child’s mother/ father 3 Child’s grandparent 4 Child’s relative under age 18 (including a sibling younger than 18) 5 Other adult relative (including a sibling 18 or older) 6 Friend or neighbor 7 Unrelated adult (including a professional at a child care center) 8 Other 88 Refused 66 Not applicable – I do not have another person who cares for my child (If not applicable, skip to question #7). |
|
If other, specify:______________________________ |
6h. Does this person help care for your child in the following locations? |
|
In the child’s home |
1 Yes 0 No 88 Refused |
In someone else’s home |
1 Yes 0 No 88 Refused |
In a childcare center/nursey |
1 Yes 0 No 88 Refused |
Other |
1 Yes 0 No 88 Refused |
|
If other, specify:______________________________ |
6i. How many days per week does this person help care for your child? |
_______ days per week 88 Refused |
6j. On days when this person helps care for your child, how many hours per day? |
_______ hours per day 88 Refused |
6k. On average, how many additional children does this person care for at the same time as your child? |
________ children 88 Refused |
6l. On average, how many additional people also provide care for your child alongside this person? |
________ people 88 Refused |
Person (3) |
|
6m. For the third person you’ve thought of, what is this person’s relationship to your child? I will read you a list of options and please select the best one. |
0 Child’s mother 1 Child’s father 2 Non-parental partner of your child’s mother/ father 3 Child’s grandparent 4 Child’s relative under age 18 (including a sibling younger than 18) 5 Other adult relative (including a sibling 18 or older) 6 Friend or neighbor 7 Unrelated adult (including a professional at a child care center) 8 Other 88 Refused 66 Not applicable – I do not have another person who cares for my child (If not applicable, skip to question #7). |
|
If other, specify:______________________________ |
6n. Does this person help care for your child in the following locations? |
|
In the child’s home |
1 Yes 0 No 88 Refused |
In someone else’s home |
1 Yes 0 No 88 Refused |
In a childcare center/nursey |
1 Yes 0 No 88 Refused |
Other |
1 Yes 0 No 88 Refused |
|
If other, specify:______________________________ |
6o. How many days per week does this person help care for your child? |
_______ days per week 88 Refused |
6p. On days when this person helps care for your child, how many hours per day? |
_______ hours per day 88 Refused |
6q. On average, how many additional children does this person care for at the same time as your child? |
________ children 88 Refused |
6r. On average, how many additional people also provide care for your child alongside this person? |
________ people 88 Refused |
How satisfied are you with the amount of help you receive in caring for your child?
5 Very satisfied
4 Somewhat satisfied
3 Not satisfied or unsatisfied
2 Somewhat unsatisfied
1 Very unsatisfied
88 Refused
Now we have questions about any crying patterns your child may be having.
How many hours per day would you say your child cries, on average:
0 <1 hour 1 1-3 hours 2 3-6 hours 3 6-9 hours 4 9-12 hours 5 >12 hours
77 Don’t know 88 Refused
In
general, how easy is it to calm your child when he or she is crying
or fussy?
0
Very easy
1 Somewhat easy
2 Somewhat difficult
3 Very difficult
77 Don’t know
88 Refused
Let’s now update our information about your child’s healthcare.
What type of health insurance does your child have?
1 Contributory 2 Subsidized 3 Not insured 4 Specialized 5 Exception
6 Indeterminate / independent 77 Don’t know 88 Refused
What is the name of your child’s health insurance provider?
Name: _________________________________________ 77 Don’t know 88 Refused
66 Not applicable
|
1 Yes 0 No 77 Don’t know 88 Refused
If Yes: Number of times:____________ Clinic name (1):_______________________________ Clinic name (2):_______________________________ Clinic name (3):_______________________________ Clinic name (4):_______________________________ Clinic name (5):_______________________________ |
|
|
Cranial ultrasound |
1 Yes 0 No 77 Don’t know 88 Refused |
|
If Yes: Number of visits:_______ Clinic name (1):___________________________________ Clinic name (2):___________________________________ |
MRI of the head |
1 Yes 0 No 77 Don’t know 88 Refused |
|
If Yes: Number of visits:_______ Clinic name (1):___________________________________ Clinic name (2):___________________________________ |
CAT scan of the head |
1 Yes 0 No 77 Don’t know 88 Refused |
|
If Yes: Number of visits:_______ Clinic name (1):___________________________________ Clinic name (2):___________________________________ |
Hearing test |
1 Yes 0 No 77 Don’t know 88 Refused |
|
If Yes: Number of visits:_______ Clinic name (1):___________________________________ Clinic name (2):___________________________________ |
Vision test |
1 Yes 0 No 77 Don’t know 88 Refused |
|
If Yes: Number of visits:_______ Clinic name (1):___________________________________ Clinic name (2):___________________________________ |
Developmental assessment |
1 Yes 0 No 77 Don’t know 88 Refused |
|
If Yes: Number of visits:_______ Clinic name (1):___________________________________ Clinic name (2):___________________________________ |
Did your child have any other tests I didn’t mention? |
1 Yes 0 No 77 Don’t know 88 Refused
If Yes: |
|
Test (1): _______________________________________ Clinic name (1):__________________________________ |
|
Test (2): _______________________________________ Clinic name (2):__________________________________ |
|
Test (3): _______________________________________ Clinic name (3):__________________________________ |
|
Test (4): _______________________________________ Clinic name (4):__________________________________ |
|
Test (5): _____________________________________ __ Clinic name (5):__________________________________ |
1 Yes 0 No 77 Don’t know 88 Refused
If YES, what type of medical specialist did your child see? Say “yes” or “no” to each one I mention. Did your child see a… |
|
Pediatrician |
1 Yes (Clinic name:_______________________________) 0 No 77 Don’t know 88 Refused |
Occupational or physical therapist |
1 Yes (Clinic name:_______________________________) 0 No 77 Don’t know 88 Refused |
Speech-language specialist |
1 Yes (Clinic name:_______________________________) 0 No 77 Don’t know 88 Refused |
Neurologist |
1 Yes (Clinic name:_______________________________) 0 No 77 Don’t know 88 Refused |
Gastroenterologist |
1 Yes (Clinic name:_______________________________) 0 No 77 Don’t know 88 Refused |
Ophthalmologist
|
1 Yes (Clinic name:_______________________________) 0 No 77 Don’t know 88 Refused |
Audiologist
|
1 Yes (Clinic name:_______________________________) 0 No 77 Don’t know 88 Refused |
ENT |
1 Yes (Clinic name:_______________________________) 0 No 77 Don’t know 88 Refused |
Geneticist |
1 Yes (Clinic name:_______________________________) 0 No 77 Don’t know 88 Refused |
Developmental Specialist
|
1 Yes (Clinic name:_______________________________ Type of specialist: ________________________________) 0 No 77 Don’t know 88 Refused |
Did your child see any other type of medical provider I didn’t mention? |
1 Yes (Provider type:_______________________________ Clinic name:________________________________) 0 No 77 Don’t know 88 Refused |
|
1 Yes 0 No 77 Don’t know 88 Refused If Yes: Number of times:____________ Hospital name (1):_______________________________ Hospital name (2):_______________________________ Hospital name (3):_______________________________ Hospital name (4):_______________________________ Hospital name (5):_______________________________
|
|
|
Zika virus |
1 Yes 0 No 77 Don’t know 88 Refused |
Dengue |
1 Yes 0 No 77 Don’t know 88 Refused |
Chikungunya |
1 Yes 0 No 77 Don’t know 88 Refused |
Yellow Fever |
1 Yes 0 No 77 Don’t know 88 Refused |
Cytomegalovirus |
1 Yes 0 No 77 Don’t know 88 Refused |
Rubella |
1 Yes 0 No 77 Don’t know 88 Refused |
Toxoplasmosis |
1 Yes 0 No 77 Don’t know 88 Refused |
Syphilis |
1 Yes 0 No 77 Don’t know 88 Refused |
Chicken Pox |
1 Yes 0 No 77 Don’t know 88 Refused |
Parvovirus |
1 Yes 0 No 77 Don’t know 88 Refused |
Herpes |
1 Yes 0 No 77 Don’t know 88 Refused
|
Did they tell you your child had something else I didn’t mention? |
1 Yes 0 No 77 Don’t know 88 Refused If Yes, specify: _____________________________________ |
Since your last study visit, have you or your child enrolled in another Zika virus study?
1 Yes, I did Which study? _______________________________________________
2 Yes, my child did Which study? _______________________________________________
3 Yes, my child and I did Which study? ___________________________________________
0 No
77 Don’t know
88 Refused
Next, we have additional questions about your relationships, family and friends.
What is your marital status?
1 Married
2 Free Union
3 Single, divorced, or widowed
4 Other, specify: ______________
77 Don’t know
88 Refused
We are interested in how you feel about the following statements. I will read each statement to you from your point of view. Please indicate how you feel about each statement.
|
Very strongly disagree (1) |
Strongly disagree (2) |
Mildly disagree (3) |
Neutral (4) |
Mildly Agree (5) |
Strongly agree (6) |
Very strongly agree (7) |
Refused (88) |
There is a special person who is around when I am in need. |
|
|
|
|
|
|
|
|
There is a special person with whom I can share my joys and sorrows. |
|
|
|
|
|
|
|
|
My family really tries to help me. |
|
|
|
|
|
|
|
|
I get the emotional help and support I need from my family. |
|
|
|
|
|
|
|
|
I have a special person who is a real source of comfort to me. |
|
|
|
|
|
|
|
|
My friends really try to help me. |
|
|
|
|
|
|
|
|
I can count on my friends when things go wrong. |
|
|
|
|
|
|
|
|
I can talk about my problems with my family. |
|
|
|
|
|
|
|
|
I have friends who with whom I can share my joys and sorrows. |
|
|
|
|
|
|
|
|
There is a special person in my life who care about my feelings. |
|
|
|
|
|
|
|
|
My family is willing to help me make decisions. |
|
|
|
|
|
|
|
|
I can talk about my problems with my friends. |
|
|
|
|
|
|
|
|
Now, we have a few questions about any concerns you might have about your financial situation.
How often would you say you worry about having enough money to pay for things you need, such as food, shelter, or clothes for you and your family?
4 Always 3 Often 2 Sometimes 1 Rarely 0 Never 77 Don’t know 88 Refused
Since your last study clinic visit, have you ever been unable to pay or delayed payment for medical care, including medications, hospital stays, and doctors' visits?
1 Yes 0 No 77 Don’t know 88 Refused
Lastly, we have a few questions about your household environment.
Since your last study clinic visit, has anyone done any of the following things in the child’s house? Say “yes” or “no” to each option.
Used any pesticides, insecticides, or rat poison in or around your home |
1 Yes 0 No 77 Don’t know 88 Refused |
Smoked cigarettes inside your home? |
1 Yes 0 No 77 Don’t know 88 Refused |
Smoked marijuana inside your home? |
1 Yes 0 No 77 Don’t know 88 Refused |
Used drugs such as crack, cocaine, or heroin? |
1 Yes 0 No 77 Don’t know 88 Refused |
Thank you for completing this questionnaire. Please let me know if you have any questions.
Note any questions from parents below:_______________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Page
Appendix F9, version 08FEB2018
CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0920-1190).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Ailes, Elizabeth (CDC/ONDIEH/NCBDDD) |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |