SEED - Questionaire Packets

S

Form Approved

OMB NO. 0920-0741

Exp. Date 6/30/2010

tudy ID #: _________________

Study to Explore Early Development

AUTOIMMUNE DISEASE SURVEY

Please mark your relationship to the child in the study:

_{ Birth Mother  Birth Father  Step Mother  Step Father}

_{ Grandparent on Mother’s side  Grandparent on Father’s side}

_{ Other: (Specify) _____________________}

Instructions: Before we begin, it is important for us to be able to know the relationship of each of the brothers and sisters to the study child, in the order of oldest to youngest. In the table below, please write the name of the brother or sister and their date of birth. Then, check the correct box for sex and relationship to the study child.

Name (Start with #1 for the oldest brother or sister)	Date of birth (MM/DD/YYYY)	Sex	Relationship to the Child in the Study
#1	__ __/__ __/__ __ __ __	□ Male □ Female	□ Full brother/sister □ Half brother/sister
#2	__ __/__ __/__ __ __ __	□ Male □ Female	□ Full brother/sister □ Half brother/sister
#3	__ __/__ __/__ __ __ __	□ Male □ Female	□ Full brother/sister □ Half brother/sister
#4	__ __/__ __/__ __ __ __	□ Male □ Female	□ Full brother/sister □ Half brother/sister
#5	__ __/__ __/__ __ __ __	□ Male □ Female	□ Full brother/sister □ Half brother/sister
#6	__ __/__ __/__ __ __ __	□ Male □ Female	□ Full brother/sister □ Half brother/sister

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 20 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 (0920-0741)

The table below lists autoimmune conditions. These conditions occur when the body produces a substance (antibodies) against itself that can damage parts of the body. We are interested in knowing these conditions for the birth mother and birth father of the study child, the study child, and the brothers and sisters (including half brothers and sisters) of the study child.

Please fill out the information for each condition listed in the table. If a family member has one of the conditions, please place a  in the box for the person in that column. On the dashed lines underneath the marked box, write the age at which a diagnosis was first made for this person. If none of your family members have the condition, please mark the box in the “None” column. If you don’t know the meaning of the condition, please use the Glossary. If you still don’t know the meaning of the condition after reviewing the Glossary, please mark the box in the “Don’t Know” column.

Note: For the brothers and sisters of the study child, please use the same color-coded number of the child from the table above to fill out the table below.

Condition	Mother	Father	Study CHILD	Brothers/Sisters #1 #2 #3 #4 #5 #6	None	Don’t Know
Addison’s Disease	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Ankylosing Spondylitis	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Aplastic Anemia	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Asthma	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Autoimmune Hepatitis	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Celiac Disease	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Crohn’s Disease	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Dermatitis Herpetiformis	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Diabetes: Uses insulin	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Diabetes: Does not use insulin	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Diabetes: Gestational diabetes (Diabetes during pregnancy only)	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Eczema/psoriasis	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Giant Cell Arteritis	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Graves Disease	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Guillain-Barre Syndrome	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Hashimoto Thyroiditis	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Hemolytic Anemia	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Hyperthyroidism	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Hypothyroidism	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Irritable Bowel Syndrome	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Lupus, or Systemic Lupus Erythematosus (SLE)	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Migraine Headaches	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Mixed Connective Tissue Disease	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Multiple Sclerosis	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Myasthenia Gravis	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Narcolepsy	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Optic Neuritis	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Pemphigus	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Reiter’s Syndrome	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Rheumatoid Arthritis	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Scleroderma (progressive systemic sclerosis, CREST)	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Sjogren’s Syndrome	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Stevens-Johnson Syndrome	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Sydenham’s Chorea	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Thrombocytopenia, (immune, idiopathic)	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Tourette’s Syndrome	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Ulcerative Colitis	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
Other. (List the condition)
1.	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
2.	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
3.	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		
4.	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		