SEED - Questionaire Packets

Study ID #: _________________

Study to Explore Early Development

Date of Completion: ________

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: Please fill in the table below for each of the study child’s brothers and sisters. List them in order, from oldest to youngest.

Name (List oldest to youngest)	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 check 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 check “None”. 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 check “Don’t Know”.

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.	 ------	 ------	 ------	      ------ ------ ------ ------ ------ ------		

Version 9-07 SNC Page 7 of 7