Form 22.1 Log

OMB #: 0925-0593

Expiration Date: 07/31/2013

Infant and Child Health Care Log, Phase II

Infant and Child Health Care Log

(Birth to 6 years old)

CHILD’S LAST NAME:

__________________

CHILD’S FIRST NAME:

__________________

CHILD’S DATE OF BIRTH: _ _ / _ _ / _ _ _ _

month day year

BRING THIS LOG TO ALL HEALTH CARE VISITS.

USE THIS LOG FOR ALL NATIONAL CHILDREN’S STUDY TELEPHONE CALLS AND VISITS.

PLEASE TELL NCS STAFF WHEN MORE FORMS ARE NEEDED.

Save all bottles and containers of medications. Bring to National Children’s Study visits and have available for telephone calls:

• Medicines (those prescribed by a health care provider and those bought “over-the-counter”)

• Vitamins, minerals, herbs, and any other supplements

Public reporting for 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD

20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.

Infant and Child Health Care Log

This Infant and Child Health Care Log will help you keep track of all your child’s visits to doctors or other health care providers from birth to 6 years old. We will ask you about your child’s visits whenever we interview you by telephone or in person.

A Health Care Provider can be:	Health Care Visits can be to:
Pediatrician or family medicine doctor	Doctor’s office, clinic or health center
Specialist (like a surgeon, heart doctor, allergy or skin doctor)	Emergency room
Nurse practitioner or physician assistant	Urgent care center
Nurse	Hospital (inpatient, overnight stay)
Social worker/counselor	Some other place
Other

The log has two parts:

1. Health Care Provider Log is to record information about where your child visits the doctor or other health care provider.

2. Health Care Visit Log is to record information about all of your child’s visits to doctors, other healthcare providers, or an emergency room. This includes overnight hospital stays as well as outpatient visits.

BRING this Infant and Child Health Care Log with you to all of your child’s health care and National Children’s Study visits. Also, have it available for all National children’s Study telephone interviews.

If you forget to bring it with you to a health care visit, please fill it in as soon as possible.

Save all bottles and containers of medications and bring to National Children’s Study visits and have available for telephone calls:

• Medicines (those prescribed by a health care provider and those bought “over-the-counter”)

• Vitamins, minerals, herbs, and any other supplements

HEALTH CARE PROVIDER LOG INSTRUCTIONS

The Health Care Provider is the person who cared for your child at this visit (doctor, nurse, social worker, etc.)

Column 1. A number is listed for each health care provider (for example, 1, 2, 3, 4, etc.). This number will be referred to on the Health Care Visit Log pages.

Column 2. Attach the health care provider’s business card here.

Fill in columns 3-10 only if you have not attached the health care provider’s business card.

Column 3. Write in the name of the health care provider.

Column 4. Check the box for the type of provider. If it was “Other,” write the type of health care provider.

Column 5. Check the box for the type of place where you saw the provider. If it was “Other place,” write in the type of place where your child visited the health care provider.

Columns 6-9. Write in the address of the place including city/town, state, and ZIP code.

Column 10. Write in the telephone number of the health care provider including area code.

See the example in the first line of the log on the next page.

After you fill out the Health Care Provider Log, please fill out the Health Care Visit Log.

Inform the National Children’s Study staff when more Log pages are needed.

HEALTH CARE PROVIDER LOG
1	2	Fill in ONLY if you HAVE NOT attached a business card
		3	4	5	6	7	8	9	10
Health Care Provider Number	Attach Health Care Provider Business Card	Name of Health Care Provider/Clinic/Hospital	Type of Health Care Provider	Type of Place	Street Address	City or Town	State	Zip Code	Telephone Number
0		Dr. Joe Jones	X Pediatrician or Family Physician  Specialist  Nurse practitioner or physician assistant  Nurse  Social Worker/counselor  Other(specify): ______________	X Doctor’s office, clinic, or health center Emergency room  Urgent care center  Hospital  Other place (specify): ______________	400 Main Street	Capitol City	MN	56087	(507) -123 -4567
1			 Pediatrician or Family Physician  Specialist  Nurse practitioner or physician assistant  Nurse  Social Worker/counselor  Other (specify): ______________	 Doctor’s office, clinic, or health center Emergency room  Urgent care center  Hospital  Other place (specify): ______________
2			 Pediatrician or Family Physician  Specialist  Nurse practitioner or physician assistant  Nurse  Social Worker/counselor  Other (specify): ______________	 Doctor’s office, clinic, or health center Emergency room  Urgent care center  Hospital  Other place (specify): ______________

HEALTH CARE PROVIDER LOG
1	2	Fill in ONLY if you HAVE NOT attached a business card
		3	4	5	6	7	8	9	10
Health Care Provider Number	Attach Health Care Provider Business Card	Name of Health Care Provider/Clinic/Hospital	Type of Health Care Provider	Type of Place	Street Address	City or Town	State	Zip Code	Telephone Number
3			 Pediatrician or Family Physician  Specialist  Nurse practitioner or physician assistant  Nurse  Social Worker/counselor  Other (specify): ______________	 Doctor’s office, clinic, or health center Emergency room  Urgent care center  Hospital  Other place (specify): ______________
4			 Pediatrician or Family Physician  Specialist  Nurse practitioner or physician assistant  Nurse  Social Worker/counselor  Other (specify): ______________	 Doctor’s office, clinic, or health center Emergency room  Urgent care center  Hospital  Other place (specify): ______________
5			 Pediatrician or Family Physician  Specialist  Nurse practitioner or physician assistant  Nurse  Social Worker/counselor  Other (specify): ______________	 Doctor’s office, clinic, or health center Emergency room  Urgent care center  Hospital  Other place (specify): ______________

HEALTH CARE PROVIDER LOG
1	2	Fill in ONLY if you HAVE NOT attached a business card
		3	4	5	6	7	8	9	10
Health Care Provider Number	Attach Health Care Provider Business Card	Name of Health Care Provider/Clinic/Hospital	Type of Health Care Provider	Type of Place	Street Address	City or Town	State	Zip Code	Telephone Number
6			 Pediatrician or Family Physician  Specialist  Nurse practitioner or physician assistant  Nurse  Social Worker/counselor  Other (specify): ______________	 Doctor’s office, clinic, or health center Emergency room  Urgent care center  Hospital  Other place (specify): ______________
7			 Pediatrician or Family Physician  Specialist  Nurse practitioner or physician assistant  Nurse  Social Worker/counselor  Other (specify): ______________	 Doctor’s office, clinic, or health center Emergency room  Urgent care center  Hospital  Other place (specify): ______________
8			 Pediatrician or Family Physician  Specialist  Nurse practitioner or physician assistant  Nurse  Social Worker/counselor  Other (specify): ______________	 Doctor’s office, clinic, or health center Emergency room  Urgent care center  Hospital  Other place (specify): ______________

Inform the National Children’s Study staff when more pages are needed.

HEALTH CARE VISIT LOG INSTRUCTIONS

Office and Outpatient Visits and Overnight Hospital Stays

Each time your child goes to the doctor or any other health care provider (for example, doctor, nurse, social worker, etc.) or is hospitalized overnight, write down information about the visit on a new line in the Health Care Visit Log.

Please try to fill in columns 1-3 before the visit. If possible, ask your health care provider or the office staff to fill out columns 4-10. If that is not possible, please fill out columns 4-10 at the visit or as soon as possible.

Column 1. Health care visit date (month/day/year).

Column 2. Write the Health Care Provider number from Column 1 in the Health Care Provider Log.

Column 3. Check (√) the reason(s) for the visit and explain if needed. Include office/outpatient visits and overnight hospital stays.

For example: If your child got a well-baby check up, put a check (√) in the “check-up/well child visit” box.

Columns 4-6. Write in your child’s weight, and length or height at the visit. Write in the head circumference through age 2. If these measurements were not done, check (√) “Not Done.”

For example: If your child is 22 inches long at his visit, write in “22” inches.

Column 7. If your child got an immunization/vaccination/shot during the visit, put a check (√) in the “YES” box and Go to the Immunization/Vaccination/Shot Log.

Column 8. If your child gets any test, medication, or treatment during his/her visit, put a check (√) next to the medication/treatment and list each.

Column 9. Write what the health care provider told you (the diagnosis) at the visit. Include a few key words to describe the event or diagnosis.

For example: For a check-up or well child visit, the doctor may have told you that your child is ‘growing normally and is healthy’ or ‘has an ear infection.’ Write this down in the ‘Diagnosis’ column.

Column 10. Check the box to show if the office staff filled out the log or if you did. After you report the visit to the NCS study staff, please write in the date you told us about that visit.

See the example in the first line of the log on the next page.

Inform the National Children’s Study staff when more Log pages are needed.

LOG FOR OUTPATIENT HEALTH CARE VISITS AND OVERNIGHT HOSPITAL STAYS
1	2	3	4	5	6	7	8	9	10
Date of visit	Health Care Provider # from Health Care Provider Log	Reason for visit (check all that apply)	Weight	Length/ Height	Head circumference (0-2 yrs.)	Immunization/ Vaccination/ Shot	Tests/ Medications/ Treatments e.g., lab tests (blood, urine. . .), medicines, vitamins, minerals, herbs, supplements, procedures	Diagnosis or Problem	Completed by Office or Self
									Date Reported to NCS
March 3, 2010	0	√ Routine well visit Sick visit Specialist doctor visit Emergency visit Immunization/ vaccination/ shot Follow-up visit Overnight hospital stay How many nights? ___ Some other reason (explain): _________________________	__10__lb pounds _4___ oz. ounces OR ______kg kilograms Not Done/Don’t Know	__23_ in Inches OR _____cm centimeters Not Done/Don’t Know	__37_ cm centimeters OR _____ in Inches Not Done/Don’t Know	NO √ YES, If ‘YES’ then go to Immunization / Vaccination / Shot Log	Lab test (blood)	Well infant, good growth and development	√ Office  Self
									Date: March 4, 2011
		Routine well visit Sick visit Specialist doctor visit Emergency visit Immunization/vaccination/shot Follow-up visit Overnight hospital stay How many nights? ____ Some other reason (explain): _________________________	_______lb pounds ______ oz. ounces OR _______ kg kilograms Not Done/Don’t Know	_______ in Inches OR _______cm centimeters Not Done/Don’t Know	________ cm centimeters OR ________ in Inches Not Done/Don’t Know	NO YES, If ‘YES’ then go to Immunization / Vaccination / Shot Log			 Office  Self
									Date: _________
		Routine well visit Sick visit Specialist doctor visit Emergency visit Immunization/vaccination/shot Follow-up visit Overnight hospital stay How many nights? ____ Some other reason (explain): _________________________	_______lb pounds ______ oz. ounces OR _______ kg kilograms Not Done/Don’t Know	_______ in Inches OR _______cm centimeters Not Done/Don’t Know	________ cm centimeters OR ________ in Inches Not Done/Don’t Know	NO YES, If ‘YES’ then go to Immunization / Vaccination / Shot Log			 Office  Self
									Date: _________
LOG FOR OUTPATIENT HEALTH CARE VISITS AND OVERNIGHT HOSPITAL STAYS
1	2	3	4	5	6	7	8	9	10
Date of visit	Health Care Provider # from Health Care Provider Log	Reason for visit (check all that apply)	Weight	Length/ Height	Head circumference (0-2 yrs.)	Immunization/ Vaccination/ Shot	Tests/ Medications/ Treatments e.g., lab tests (blood, urine. . .), medicines, vitamins, minerals, herbs, supplements, procedures	Diagnosis or Problem	Completed by Office or Self
									Date Reported to NCS
		Routine well visit Sick visit Specialist doctor visit Emergency visit Immunization/vaccination/shot Follow-up visit Overnight hospital stay How many nights? ____ Some other reason (explain): _________________________	_______lb pounds ______ oz. ounces OR _______ kg kilograms Not Done/Don’t Know	_______ in Inches OR _______cm centimeters Not Done/Don’t Know	________ cm centimeters OR ________ in Inches Not Done/Don’t Know	NO YES, If ‘YES’ then go to Immunization / Vaccination / Shot Log			 Office  Self
									Date: _________
		Routine well visit Sick visit Specialist doctor visit Emergency visit Immunization/vaccination/shot Follow-up visit Overnight hospital stay How many nights? ____ Some other reason (explain): _________________________	_______lb pounds ______ oz. ounces OR _______ kg kilograms Not Done/Don’t Know	_______ in Inches OR _______cm centimeters Not Done/Don’t Know	________ cm centimeters OR ________ in Inches Not Done/Don’t Know	NO YES, If ‘YES’ then go to Immunization / Vaccination / Shot Log			 Office  Self
									Date: _________
		Routine well visit Sick visit Specialist doctor visit Emergency visit Immunization/vaccination/shot Follow-up visit Overnight hospital stay How many nights? ____ Some other reason (explain): _________________________	_______lb pounds ______ oz. ounces OR _______ kg kilograms Not Done/Don’t Know	_______ in Inches OR _______cm centimeters Not Done/Don’t Know	________ cm centimeters OR ________ in Inches Not Done/Don’t Know	NO YES, If ‘YES’ then go to Immunization / Vaccination / Shot Log			 Office  Self
									Date: _________

LOG FOR OUTPATIENT HEALTH CARE VISITS AND OVERNIGHT HOSPITAL STAYS
1	2	3	4	5	6	7	8	9	10
Date of visit	Health Care Provider # from Health Care Provider Log	Reason for visit (check all that apply)	Weight	Length/ Height	Head circumference (0-2 yrs.)	Immunization/ Vaccination/ Shot	Tests/ Medications/ Treatments e.g., lab tests (blood, urine. . .), medicines, vitamins, minerals, herbs, supplements, procedures	Diagnosis or Problem	Completed by Office or Self
									Date Reported to NCS
		Routine well visit Sick visit Specialist doctor visit Emergency visit Immunization/vaccination/shot Follow-up visit Overnight hospital stay How many nights? ____ Some other reason (explain): _________________________	_______lb pounds ______ oz. ounces OR _______ kg kilograms Not Done/Don’t Know	_______ in Inches OR _______cm centimeters Not Done/Don’t Know	________ cm centimeters OR ________ in Inches Not Done/Don’t Know	NO YES, If ‘YES’ then go to Immunization / Vaccination / Shot Log			 Office  Self
									Date: _________
		Routine well visit Sick visit Specialist doctor visit Emergency visit Immunization/vaccination/shot Follow-up visit Overnight hospital stay How many nights? ____ Some other reason (explain): _________________________	_______lb pounds ______ oz. ounces OR _______ kg kilograms Not Done/Don’t Know	_______ in Inches OR _______cm centimeters Not Done/Don’t Know	________ cm centimeters OR ________ in Inches Not Done/Don’t Know	NO YES, If ‘YES’ then go to Immunization / Vaccination / Shot Log			 Office  Self
									Date: _________
		Routine well visit Sick visit Specialist doctor visit Emergency visit Immunization/vaccination/shot Follow-up visit Overnight hospital stay How many nights? ____ Some other reason (explain): _________________________	_______lb pounds ______ oz. ounces OR _______ kg kilograms Not Done/Don’t Know	_______ in Inches OR _______cm centimeters Not Done/Don’t Know	________ cm centimeters OR ________ in Inches Not Done/Don’t Know	NO YES, If ‘YES’ then go to Immunization / Vaccination / Shot Log			 Office  Self
									Date: _________

LOG FOR OUTPATIENT HEALTH CARE VISITS AND OVERNIGHT HOSPITAL STAYS
1	2	3	4	5	6	7	8	9	10
Date of visit	Health Care Provider # from Health Care Provider Log	Reason for visit (check all that apply)	Weight	Length/ Height	Head circumference (0-2 yrs.)	Immunization/ Vaccination/ Shot	Tests/ Medications/ Treatments e.g., lab tests (blood, urine. . .), medicines, vitamins, minerals, herbs, supplements, procedures	Diagnosis or Problem	Completed by Office or Self
									Date Reported to NCS
		Routine well visit Sick visit Specialist doctor visit Emergency visit Immunization/vaccination/shot Follow-up visit Overnight hospital stay How many nights? ____ Some other reason (explain): _________________________	_______lb pounds ______ oz. ounces OR _______ kg kilograms Not Done/Don’t Know	_______ in Inches OR _______cm centimeters Not Done/Don’t Know	________ cm centimeters OR ________ in Inches Not Done/Don’t Know	NO YES, If ‘YES’ then go to Immunization / Vaccination / Shot Log			 Office  Self
									Date: _________
		Routine well visit Sick visit Specialist doctor visit Emergency visit Immunization/vaccination/shot Follow-up visit Overnight hospital stay How many nights? ____ Some other reason (explain): _________________________	_______lb pounds ______ oz. ounces OR _______ kg kilograms Not Done/Don’t Know	_______ in Inches OR _______cm centimeters Not Done/Don’t Know	________ cm centimeters OR ________ in Inches Not Done/Don’t Know	NO YES, If ‘YES’ then go to Immunization / Vaccination / Shot Log			 Office  Self
									Date: _________
		Routine well visit Sick visit Specialist doctor visit Emergency visit Immunization/vaccination/shot Follow-up visit Overnight hospital stay How many nights? ____ Some other reason (explain): _________________________	_______lb pounds ______ oz. ounces OR _______ kg kilograms Not Done/Don’t Know	_______ in Inches OR _______cm centimeters Not Done/Don’t Know	________ cm centimeters OR ________ in Inches Not Done/Don’t Know	NO YES, If ‘YES’ then go to Immunization / Vaccination / Shot Log			 Office  Self
									Date: _________

Inform the National Children’s Study staff when more pages are needed.

IMMUNIZATION / VACCINATION / SHOT LOG INSTRUCTIONS Write in the date of the immunization/vaccination/shot. Put a √ in the box of each vaccine(s) given to your child. Ask your child’s Health Care Provider to help you to check all of the right boxes. At the bottom of the Log, write in if your child had any problems after any of the immunizations, vaccinations or shots. CONTACT YOUR CHILD’S DOCTOR IF YOUR CHILD HAS ANY PROBLEMS AFTER AN IMMUNIZATION/ SHOT/ VACCINATION.

IMMUNIZATION / VACCINATION / SHOT LOG

Needles or injections

By Mouth

Needle

Nasal Mist

Combination vaccines

DATE OF IMMUNIZATION

Hepatitis B (Hep B)

Diphtheria, Tetanus, and Pertussis (whooping cough) (DTaP)

H. Influenza Type B (Hib)

Inactivated Polio (IPV)

Pneumococcal Conjugate (PCV7)

Measles, Mumps, and Rubella (MMR)

Measles, Mumps, Rubella, and Varicella (MMRV)

DTaP, Hep B, and IPV

Hib and Hep B

DTaP and Hib

DTaP and IPV

DTaP , IPV, and Hib

Varicella (Chickenpox)

Hepatitis A

Meningococcal

Palivizumab to prevent RSV (Respiratory Syncytial Virus)

Rotavirus

Influenza (Seasonal ‘Flu’)

Influenza (Seasonal ‘Flu’)

Other

March 3, 2011

√

√

XYZ Vaccine

ANY PROBLEMS AFTER A SHOT/IMMUNIZATION/VACCINATION?

DATE OF THE Immunization / Vaccination / Shot

DATE YOU FIRST NOTICED THE PROBLEM

DESCRIBE THE PROBLEM

Inform the National Children’s Study staff when more pages are needed.