UMMC Anthropometric Data
Information Collection on Soil-transmitted Helminth Infections in Alabama and Mississippi
Attachment E. UMMC Anthropometric data_FINAL_OMB edits_06202019 clean (OMB)_AS 09232019_CLEAN
Anthropometric measurements - Mississippi
OMB: 0920-1271
Sex
(please
circle): Insurance:
Female – Male –
prefer not to answer Private - Government - none - prefer not
to answer
Ethnicity:
Hispanic/Latino Not Hispanic/Latino Unknown Prefer not to
answer Race
(mark all that apply):
White
Black/African
American
Asian
American
Indian/Alaska Native
Native
Hawaiian/Pacific Islander
Unknown
Prefer
not to answer
OMB Control No. 0920-****
Exp.
Date **/**/2019
| HOBBS, Charlotte, PI
Parasite Surveillance
Project | UMMC
IRB #2016-0111
In what country was your
child born?
First
Name*: Middle
Name (or initial):
Child / Participant
Contact Information:
Parent/Guardian Contact
Information:
/
/
Subject ID:
Date:
Month
Day
Year
First name:
Last name:
Home phone number:
Cell / Mobile phone
number:
Last
Name*: Birthdate:
Current
Home
Address: Home Zip Code:
Home
Phone#: Cell
/ Mobile
Phone#:
How long has child lived
in current home?
The 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333 ATTN: PRA (0920-****)
.
.
.
.
Height: inches Weight: lbs
Lead g/dL Hemoglobin ug/dL Date:
(MM/DD/YYYY) Date: (MM/DD/YYYY) Vision Screening:
Y or
N - OD: / -
OS: / - Date:
(MM/DD/YYYY)
Parasite Surveillance Project
| UMMC
IRB #2016-0111
| HOBBS, Charlotte, PI
/
/
Subject ID:
Month
Day
Year
Parasite Surveillance Project
| UMMC
IRB #2016-0111
| HOBBS, Charlotte, PI
Date:
Form Completed
By: Date:
COMMENTS
Version
February 2019
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Chiari Type I Malformation Radiology Review Form |
| Author | DOM PC;tracy.ohrt@wisc.edu |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |
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