Formative - Developmental

LOI2-PHYS-01 EXEMPLAR HEATH SCREEN ATTACHMENT C.3.7

OMB Number: 0925-0593

Expiration Date: July 31, 2013

STUDY ID: __ __ __ __ __

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

INTERVIEWER: __ __

HEALTH SCREEN (FOR EACH VISIT)

“These questions are about [your child]. 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.)

1) Since your last visit with us, has [your child] been sick with a cold, cough, flu symptoms, or other breathing problems? If “no” please skip to question 2	 0 - No  1 - Yes
1A) Is he/she still sick?	 0 - No  1 - Yes
1B) When did his/her illness end?	__ __ days ago
2) Has [your child] taken an inhaler or nebulized medication today? If “no” please skip to question 3	 0 - No  1 - Yes
2A) Has he/she taken Albuterol, Ventolin, ProAir, Proventil, or Xopenex?	 0 - No  1 - Yes
2B) Has he/she taken Atrovent or Ipratroprium?	 0 - No  1 - Yes
2C) Has he/she taken Advair or Symbicort?	 0 - No  1 - Yes
3) Has [your child] had any chocolate or caffeine (coffee or soda) today?	 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.