Screening Questionnaire

Green Housing Study Form Approved

Appendix D12 Screening Questionnaire OMB No. 0920-XXX

Household ID #___________

Green Housing Study

Screening Questionnaire

Public reporting burden of 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXX).

1. What is your date of birth? _____/_____/_____ (mm/dd/yy)

If mother/ primary caregiver is younger than 18 years, STOP. This household is not eligible.

2. How many children with asthma age 7 to 12 (years) do you have? _______

If answer to Question 2 is Zero (0), then STOP- not eligible.

If answer to Question 2 is ≥ 1 then ask:

How many of your child(ren) with asthma age 7 to 12 (years) meet all of the following criteria?

1. Doctor or healthcare provider ever said that he/she had asthma.

2. Child had asthma symptoms in the past 6 months.

3. Child does not have a medical condition that would make it hard for him/her to participate in the study? (PROBE cystic fibrosis, cerebral palsy)

4. Child sleeps 7 nights per week at this address, on average.

2.1 Please enter number _______

IIf answer to 2.1 is One (1), then this child is eligible, if more than 1, then the youngest child (willing) is eligible. (Please enter the following information for the eligible child)

2.1.1 What is the child’s date of birth? _____/_____/_____ (mm/dd/yy)

2.1.2 Is this child a girl or boy? (please circle) Girl Boy

IF THIS HOUSEHOLD IS ELIGIBLE, PLEASE COLLECT CONTACT INFORMATION, AND COMPLETE THE CONSENT FORM (and ASSENT FORM IF APPLICABLE)

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Contact Information

Date _____/_____/_____ (mm/dd/yy) Interviewer’s initials(max 3): ____ ____ ____

Study site code: _______________________________________ (if code not available, list housing complex)

NAME OF MOTHER/ PRIMARY CAREGIVER:

_____________________________________________________ _________________

First Last Study ID (mother/ primary caregiver)

NAME OF ENROLLED CHILD (AGE 7-12 YEARS WITH ASTHMA):

_____________________________________________________ _________________

First Last Study ID (Child with asthma 7-12)

What is your relationship to {child’s name}?

1. Mother (BIRTH)

2. Mother (ADOPTIVE/ FOSTER)

3. Mother (STEP)

4. Father (BIRTH)

5. Father (ADOPTIVE/ FOSTER)

6. Father (STEP)

7. Grandmother

8. Aunt

9. Uncle

10. Grandfather

11. Other relative

12. Unrelated

ADDRESS OF HOME:

_____________________________________________________________________________

(Street address) (Apt # or Unit #)

_____________________________________________________________________________

(City) (State) (Zip code)

Longitude ____________ Latitude ______________

Phone number: ( ) _________________________ Phone number: ( ) ________________________

(Circle one*) H – C – W – O H – C – W – O

*H=home; C=cell; W=work; O=other

E-mail address:____________________________________________________________________________

Please provide the names and phone numbers of two people who know how to reach you.

(PROBE: We really need this information ONLY if we have tried to contact you several times to set up your appointments).

1. Name of alternate contact #1:______________________________________________________

First Last

Relationship (Circle one): Parent Sibling Other relative Friend Co-worker Spouse/Partner Other

Phone number: ( ) ________________________ Phone number: ( ) ______________________

(Circle one*) H – C – W – O H – C – W – O

2. Name of alternate contact #2:_____________________________________________________

First Last

Relationship (Circle one): Parent Sibling Other relative Friend Co-worker Spouse/Partner Other

Phone number: ( ) ________________________ Phone number: ( ) ______________________

(Circle one*) H – C – W – O H – C – W – O