A.2.3.i Survey

Appendix A A.2.3.i–3

For Office Use Only

Participant # __ __ __ __ __

#__ __ __ __ __

National Children’s Study

Nail Data Collection Form

Part A: Administrative
Date: |__|__| / |__|__| / |__|2___0_|__|__|	Site ID: |___|___|___|___| Participant’s age |__|__| years Visit type T1 Father T1 Prior Father T3 Mother
Assignment ID: |___|___|___|___|___|___| Participant ID: |___|___|___|___|___|___| Data Collector ID: |___|___|___|___|
Part B: Nail Collection Questions
1) Do you use toenail polish? 1 Yes 2 No (Go to Q 3) 97 Refuse (Go to Q 3) 98 Don’t know ( Go to Q 3)
2) When was the last time that you used toenail polish? 1 Within the last week 2 Within the last month 3 Within the last 3 months 4 Within the last 6 months 5 Within the last year 6 More than 1 year 97 Refused 98 Don’t Know
3) Have you toes been treated either orally or topically with a medication for toenail fungus? 1 Yes 2 No (Go to Part C) 97 Refuse (Go to Part C) 98 Don’t know (Go to Part C)
4) When was the last time that you used an anti-fungal treatment? 1 Within the last week 2 Within the last month 3 Within the last 3 months 4 Within the last 6 months 5 Within the last year 6 More than 1 year 97 Refused 98 Don’t Know
Part C: Nail Collection
Kit ID: |___|___|___|___|___|___|___|___|___|___|___|___|
Nail collection item ID |___|___|___|___|___|___|___|___|___|___|___|___|		Collection Status (Select one) Collected 1 Not Collected 2 Reason for Not Done/Partial (Select one) Physical Limitations 1 Participant III/ Emergency 2 Defective Collection Kit 3 Communication Problem 4 No Time 5 Quantity not sufficient 6 Other Specify___________________ 96 Refused 97
From how many toes did you collect toenail clippings? |___|___|
Nail Comment: __________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

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