Form 2 Att 3 Clinic Eligibility Screening Interview

Attachment 3

Clinic Eligibility Screening Interview	OMB#: 0925-#### EXP.DATE: ##/##/2011
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 10 minutes for this questionnaire, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review 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 current, 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 (####-####).

CLINIC VISIT #1: INTRODUCTORY QUESTIONNAIRE

Instructions: The following form will be provided to participants upon arriving to the first clinic visit. Contact information will be pre-populated based on information collected during the telephone screening interview.

ID LABEL

ENROLLMENT FORM AND ELIGIBILITY SCREENER

Date: [Pre-populated Month/Day/Year]

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN

Public reporting burden for this collection of information is estimated to average 10 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 (####-####).

1. Personal Contact Information

   [Pre-populated with known information when possible]

   ____________________________________________________________________________ _____

   FIRST NAME MIDDLE INITIAL LAST NAME SUFFIX

   
   

   ____________________________________________________________________________ _____

   STREET ADDRESS CITY STATE ZIP CODE

   
   

   ____________________________________________________________________________ _____

   HOME PHONE # WORK PHONE # MOBILE PHONE #

   
   

   ____________________________________________________________________________ _____

   BEST TIME TO CALL

   
   

   ____________________________________________________________________________ _____

   EMAIL ADDRESS

   
   

Please provide the following information.

2. DATE OF BIRTH: _________/_________/_________ 3. GENDER:  MALE

MONTH DAY YEAR FEMALE

4. ETHNICITY: HISPANIC OR LATINO

NOT HISPANIC OR LATINO

5. RACE: AMERICAN INDIAN OR ALSKA NATIVE

ASIAN

BLACK OR AFRICAN AMERICAN

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

WHITE

Please answer the following questions about your internet access.

6. DO YOU HAVE ACCESS TO A COMPUTER AND HIGH-SPEED INTERNET?  YES

NO

7. ARE YOU ABLE TO ANSWER ONLINE SURVEYS THAT MAY TAKE UP TO

AN HOUR TO COMPLETE?  YES

NO

Please answer the following questions about your health.

8. ARE YOU CURRENTLY TRYING TO LOSE WEIGHT?  YES

NO

9. ARE YOU CURRENTLY USING SUPPLEMENTAL OXYGEN?  YES

NO

10. ARE YOU CURRENTLY TAKING BETA-BLOCKERS FOR A HEART CONDITION?  YES

NO

11. HAS A HEALTH PROFESSIONAL EVER TOLD YOU THAT YOU HAVE…

1. HIGH BLOOD SUGAR THAT REQUIRES DAILY INSULIN SHOTS TO CONTROL?  YES

NO

2. CONGESTIVE HEART FAILURE?  YES

NO

3. KIDNEY FAILURE THAT REQUIRES DIALYSIS?  YES

NO

4. DIFFICULTY WITH FLUID RETENTION (SWELLING OF MORE THAN 5 POUNDS)?  YES

NO

5. MALABSORPTION, FOOD ABSORPTION PROBLEMS, CHROHN’S DISEASE?  YES

NO

6. HEMOPHILIA?  YES

NO

12. DO YOU HAVE A SENSITIVITY TO THE NUTRITIONAL SUPPLEMENT CALLED PABA OR

HAVE YOU EVER DEVELOPED A RASH OR ITCHING AFTER APPLYING SUNSCREEN?  YES

NO

13. ARE YOU ABLE TO STOP TAKING MEDICATIONS CONTAINING ACETAMINOPHEN,

SULPHONIMIDES, OR VITAMIN SUPPLEMENTS FOR THE 2 DAY URINE COLLECTION?  YES

NO

14. BY YOURSELF AND WITHOUT USING ANY SPECIAL EQUIPMENT, DO YOU THINK YOU

COULD WALK FOR A QUARTER OF A MILE (ABOUT 2 OR 3 BLOCKS)?  YES

NO

15. Please provide the names of two contacts who could be reached in case we cannot reach you.

CONTACT PERSON #1

____________________________________________________________________________ _____

FIRST NAME MIDDLE INITIAL LAST NAME SUFFIX

____________________________________________________________________________ _____

STREET ADDRESS CITY STATE ZIP CODE

____________________________________________________________________________ _____

HOME PHONE # WORK PHONE # MOBILE PHONE #

____________________________________________________________________________ _____

RELATIONSHIP TO YOU

CONTACT PERSON #2

____________________________________________________________________________ _____

FIRST NAME MIDDLE INITIAL LAST NAME SUFFIX

____________________________________________________________________________ _____

STREET ADDRESS CITY STATE ZIP CODE

____________________________________________________________________________ _____

HOME PHONE # WORK PHONE # MOBILE PHONE #

____________________________________________________________________________ _____

RELATIONSHIP TO YOU

DETERMINATION OF ELIGIBILITY

Signed informed consent form

ELIGIBLE

AND

All questions 6-14 are answered ‘Yes’

Did not sign informed consent form

NOT ELIGIBLE

OR

Any question 6-14 is answered ‘No’

- END OF QUESTIONNAIRE -