Mail Verification for Interview

ATTACHMENT R

Mail Verification Form for Interview

MAIL VERIFICATION FORM FOR INTERVIEW

Form Approved:

OMB No. 0920-xxxx

Exp. Date __xx/xx/2012

[Parent Name/Resident] [DATE]

[ADDRESS]

In recent weeks, RTI International has been conducting a survey of children’s health after Hurricanes Katrina and Rita. Our records indicate that a [AGE] year old [GENDER] in your household was selected to participate. We would appreciate it if you would take a moment to complete the following questions on [HIS/HER] behalf.

This information is only used to verify the quality of our interviewer’s performance.

1. Were you interviewed in-person or over the telephone?

In-person___ Over the telephone___

2. Did the interviewer complete the interview using a computer and hand-held device?

Yes___

No___ Please explain:

3. Did the interviewer set up equipment at your home during the first visit (Session 1) and retrieve it during the second visit 5 – 9 days later (Session 2)?

Yes___ No___

4. Did the interviewer provide your child with an air quality measuring device for him/her to wear during the first visit (Session 1) and retrieve that device along with a time and activity log during the second visit 5-9 days later (Session 2)?

Yes___ No___

5. Did the interviewer ask permission for the study to review your child’s medical records?

Yes___ No___

6. Did the nurse ask to measure your child’s weight during Session 2?

Yes___ No___

7. Did the nurse ask to measure your child’s height during Session 2?

Yes___ No___

Public reporting burden of this collection of information is estimated to average 5 minutes per participant, 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-xxxx).

8. Did the nurse ask to collect a blood sample from your child during Session 2?

Yes___ No___

9. Did the nurse ask to collect a urine sample from your child during Session 2?

Yes___ No___

10. Did the nurse test your child’s lung function by having him/her breathe into a device during Session 2?

Yes___ No___

11. Were you given cash for your participation at the end of Session 1 and again at the end of Session 2?

Yes___ No___

If yes, how much total were you given? $_____

12. Was your child given cash for his/her participation (if 8 years of age and older) at the end of Session 2?

Yes___ No___

If yes, how much total was he/she given? $_____

13. Was your child given an activity book for his/her participation (if 7 years of age and younger) at the end of Session 2?

Yes___ No___

14. Was the interviewer professional and courteous?

Yes___ No___

Please describe how our interviewer could improve his/her behavior:

15. Was the nurse professional and courteous?

Yes___ No___

Please describe how our nurse could improve his/her behavior:

_________

A stamped, pre-addressed envelope is enclosed for your convenience in returning this form. Thank you for your cooperation.

S incerely,

Diane Wagener, PhD

Project Director

Children’s Health after the Storms

Mail Verification Form for Interview R-5