Formative - Developmental

LOI2-PHYS-01 EXEMPLAR SCREENING QUESTIONNAIRE ATTACHMENT C.3.2

OMB Number: 0925-0593

Expiration Date: July 31, 2013

STUDY ID: __ __ __ __ __

DATE: __ __ / __ __ / __ __ (dd/mm/yy)

INTERVIEWER: __ __

SCREENING QUESTIONNAIRE

“These questions are about [your child]. They will cover initial questions to determine if he/she is eligible to participate in the study. Please answer each question as carefully as possible. ALL INFORMATION THAT YOU GIVE WILL BE KEPT STRICTLY CONFIDENTIAL.”

(Note to interviewer: do not record “uncertain” as an answer unless the subject absolutely cannot answer. “Uncertain” should not be offered as a choice of answer. If the subject insists on responding uncertain/unsure, write a note of this response next to the question, or fill with “999…” all numeric fields.)

GENERAL SCREENING:
1) How many weeks along were you when [your child] was born?	__ __ weeks
1A) If unsure: Was it less than 34 weeks? Less than 7 ½ months?	 0 - No  1 - Yes
ASTHMA SCREENING:
2) Has [your child] ever been diagnosed with any of the following: cystic fibrosis, chronic lung disease, chronic bronchitis, or recurrent pneumonias?	 0 - No  1 - Yes
3) Has [your child] ever been diagnosed with any other diseases?	 0 - No  1 - Yes
3A) If yes: which?	_______________ _______________ _______________
4) Has [your child] had a cough, runny nose, or other cold or flu symptoms in the last 2 weeks?	 0 - No  1 - Yes
5) Has [your child] been diagnosed with pneumonia or bronchiolitis in the last 2 months?	 0 - No  1 - Yes
7) Has [your child] had an attack or recurrent attacks of wheezing?	 0 - No  1 - Yes
7A) If yes: how many in the last year?	 0 - Less than 3  1 - Three or more
8) Does [your child] have wheezing in the chest when he/she is not sick with a cold or the flu?	 0 - No  1 - Yes

Public reporting burden for this collection of information is estimated to average 5 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.