Questionaire Packets

Appendix H.2: Seven Day Stool Diary

Form Approved

OMB NO. __________

Exp. Date __________

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 40 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-XXXX)

Bristol Stool Form Scale

Type 1 Separate hard lumps, like nuts

Type 2 Sausage-shaped but lumpy

Type 3 Like a sausage or snake but with cracks on its surface

Type 4 Like a sausage or snake, smooth and soft

Type 5 Soft blobs with clear-cut edges

Type 6 Fluffy pieces with ragged edges, a mushy stool

Type 7 Watery, no solid pieces

Modified Bristol Stool Form Scale (for children who are in diapers)

Type 1 Separate hard lumps, like nuts or rabbit pellets

Type 2 Sausage-shaped but lumpy

Type 3 Like a sausage or snake but with cracks on its surface, form may be

changed slightly by sitting on stool

Type 4 Like a sausage or snake, smooth and soft, may be deformed by sitting

on stool

Type 5 Soft blobs with clear cut edges, never a sausage

Type 6 Runny, no form

Type 7 Watery, no solid pieces, soaks into diaper

Instructions for stool diary:

Please record every stool that your child has and rate the consistency based on the scale provided. Please note if the stool was in the toilet, or in a diaper or underwear. Whenever possible, please have another caregiver rate the consistency as well but please do not compare your answers. Please record any vomiting and what it was associated with. (Ex: Was your child crying so hard that they vomited? Did your child choke and then vomit?) Please choose a typical week to record your child’s stools and diet. (Ex: Don’t choose a week when you are on vacation.) If your child gets a fever or an intestinal virus you should stop the diaries and call for further instructions. If you have any questions, please call <Principal Investigator>.

Day 1

ID # ________________

Stool Number	Time of Day	Type (please use scale provided)	Relationship of rater to the child (ex. Mother, teacher)	Comments (toilet vs. diaper, etc.)	Type (as rated by second observer if available)	Relationship of rater to the child (ex.teacher, if more than one teacher please give name)

Day 2

Stool Number	Time of Day	Type (please use scale provided)	Relationship of rater to the child (ex. Mother, teacher)	Comments (toilet vs. diaper, etc.)	Type (as rated by second observer if available)	Relationship of rater to the child (ex.teacher, if more than one teacher please give name)

Day 3

Stool Number	Time of Day	Type (please use scale provided)	Relationship of rater to the child (ex. Mother, teacher)	Comments (toilet vs. diaper, etc.)	Type (as rated by second observer if available)	Relationship of rater to the child (ex.teacher, if more than one teacher please give name)

Day 4

Stool Number	Time of Day	Type (please use scale provided)	Relationship of rater to the child (ex. Mother, teacher)	Comments (toilet vs. diaper, etc.)	Type (as rated by second observer if available)	Relationship of rater to the child (ex.teacher, if more than one teacher please give name)

Day 5

Stool Number	Time of Day	Type (please use scale provided)	Relationship of rater to the child (ex. Mother, teacher)	Comments (toilet vs. diaper, etc.)	Type (as rated by second observer if available)	Relationship of rater to the child (ex.teacher, if more than one teacher please give name)

Day 6

Stool Number	Time of Day	Type (please use scale provided)	Relationship of rater to the child (ex. Mother, teacher)	Comments (toilet vs. diaper, etc.)	Type (as rated by second observer if available)	Relationship of rater to the child (ex.teacher, if more than one teacher please give name)

Day 7

Stool Number	Time of Day	Type (please use scale provided)	Relationship of rater to the child (ex. Mother, teacher)	Comments (toilet vs. diaper, etc.)	Type (as rated by second observer if available)	Relationship of rater to the child (ex.teacher, if more than one teacher please give name)

Thank you so much for your participation in this study. Please fill out the last few questions and mail the diet record and the stool record back to us in the self addressed stamped envelope that was given to you. If you have any questions, please call <Principal Investigator>.

1. Was this a typical week for your child? __Yes, __No. If not, what was different or stressful for your child? _________________________________

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2. Do you feel that you recorded a typical week for diet? __Yes, __No. If not, what was different? _____________________________________________

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3. Do you feel that you recorded a typical week for stools? __Yes, __No. If not, what was different? _____________________________________________

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4. Do you have any comments about this study or suggestions for better ways to collect the diet or stool records for future projects? _____________________

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