Multi-site Study Medical Record Abstraction Form - Child

Attachment 17b.

Multi-Site Study

Medical Record Abstraction Form - Child

Flesch-Kincaid Readability Score – 12.5

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/201x xx/xx/20xxExDaxx/xx/20xx

Exp. Date xx/xx/20xx

Agency for Toxic Substances and Disease Registry (ATSDR)

ATSDR estimates the average public reporting burden for this collection of information as 20 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 (0923-xxxx).

Multi-Site Study

Medical Record Abstraction Form - Child

Study ID: [____________]

Participant Name: [_____________________________________]

Date of Birth: ___/___/_____

SSN: xxx-xx-xxxx

The person named above, or his or her legal representative, has authorized you to release his or her medical records to [institution name] and ATSDR for research purposes. Please check If you have a record that a doctor or other health care provider diagnosed or is treating any of the following medical conditions.

Please fill out the table below. Circle appropriate response and specify requested details as directed. Thank you.

Medical Condition	Record Located (Comments)	Year of Diagnosis or Treatment
Allergies?	Yes (Please specify diagnosis)_____________________ No
Atopic dermatitis/eczema?	Yes No
Asthma?	Yes No
Rhinitis?	Yes No
High cholesterol?	Yes No
Thyroid disease?	Yes (Please specify diagnosis)_____________________ No
Delayed puberty?	Yes (Please specify diagnosis)_____________________ No
Obesity?	Yes No
Lupus	Yes No
Celiac disease	Yes No
Diabetes type 1	Yes No
Diabetes type 2	Yes No
Attention deficit hyperactivity disorder (ADHD) or attention deficit disorder (ADD)?	Yes (Please specify diagnosis) ______________________ No
Autism?	Yes No
OOther learning or behavioral problems?	Yes (Please specify diagnosis) ______________________ No
o. Cancer?	Yes (Please specify diagnosis) ______________________ No
Other cancer?	Yes (Please specify diagnosis) ______________________ No
Pregnancy induced hypertension/preeclampsia?	Yes (Please specify diagnosis) ______________________ No
Gestational Diabetes?	Yes No