Form 1 Screener and Core Questionnaire AsiaLymph

AsiaLymph Study
Screener and Questionnaire

OMB #: 0925-XXXX
Expiration date: XX/XX/20XX
Public reporting for this collection of information is estimated to average 75 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-XXXX). Do not return the completed
form to this address.

Screener

1

Questionnaire

2

If No (0) Siblings,
Go To 1C.1

3

4

If Yes, Go To
INTRO for 1D.4
If No or Don’t Know,
Go To INTRO for 2A.1

INTRO for 1D.4

Go To 1D.4 and begin completing grid
When you have obtained 1D.4-1D.7 for all jobs (up to 12 total jobs available for
entry on CAPI), GO TO 1D.8 for 1st job. Then ask 1D.8 through 1D.16 for the first
job and then repeat for all additional jobs

5

1st Job Questions

2nd Job Questions

6

3rd Job Questions

Note: After asking questions 1D.8 through 1D.16 for the last job,
Go To 1D.17 INTRO.

If NO, Go To OccIDEAS
transition screen.

If NO, Go To OccIDEAS
transition screen.

7

OccIDEAS Transition Screen

8

If No or Don’t Know
Go To 2A3.1

If No or Don’t Know,
Go To 2A3.1

9

If No or Don’t Know
Go To 2A4.1

10

If No or Don’t Know
Go to 2B.1

If No or Don’t Know,
Go To 2B.1

11

If No or Don’t Know,
Go To 2C.1

NOTE: CAPI has fields to enter up to 8 different transfusions

12

If No or Don’t Know,
Go To 2D.1

CAPI NOTE: The CAPI has fields for 8 different hospitalizations.
If No or Don’t Know,
Go To 2D.1

13

For Females:

For Males

14

15

If No or Don’t Know,
Go To 2D.3

16

If No or Don’t Know,
Go To Section F

17

If No or Don’t Know,
Go To 2F1.2

If No or Don’t Know,
Go To 2F1.3

18

If No or Don’t Know,
Go To 2F1.4

If No or Don’t Know,
Go To 2F1.5

If No or Don’t Know,
Go To 2F.2

19

If No or Don’t Know,
Go To INTRO for 3A.1

CAPI has fields to enter up to 16 family members

20

INTRO for 3A.1

21

IF SUBJECT IS LESS THAN AGE 40, Go To Section 3B.
IF SUBJECT IS AGE 40-49, begin next question with “Since you became age 40, in the
summer months…”
IF SUBJECT IS AGE 50+ ask the next question as shown below.

22

If No or Don’t Know,
Go To 3C.1
If still
using Go
To 2a etc.

NOTE: In CAPI room for 10
different hair dyes or any hair
colouring products

23

If No,
Go To 3C.6

IF SUBJECT IS LESS THAN AGE 40, Go To SECTION 3D INTRO.
IF SUBJECT IS AGE 40-49, Continue.
IF SUBJECT IS AGE 50+, include “and fifties” in 3C.7 INTRO and 3C.9

If No,
Go To 3C.12

24

25

26

27

28

If No,
Go To 3G.1

If Yes,
Go To 3F.6
If No,
Go To 3F.4

Go To 3F.12

If No,
Go To 3F.14

29

If No,
Go To 3F.16

If No,
Go To 3G.1

30

If No,
Go To 3H CAPI NOTE

If Never,
Go To 3Ga.2

If Never,
Go To 3Ga.3

31

If Never,
Go To 3Ga.4

If Never,
Go To 3Ga.5

If Never,
Go To 3H CAPI NOTE

32

CAPI NOTE: For Women Only; Skip to Part IV for Male Subjects.

If Never had a
period, Go To 3H.7

If Yes,
Go to 3H.7

If No,
Go to PART IV

33

If 0 pregnancies,
Go To PART IV.
If 0 live births,
Go To PART IV.

If 3H.9 is 1, answer 3H.10 then
Go To 3H.12

If No,
Go to PART IV

34

PART IV

THE CAPI PROVIDES SPACE FOR UP TO 10 CHILDHOOD AND ADULT RESIDENCES.

35

Residence #1

If Family,
Go To 4B1.6

If Friends or
Others,
Go To 4B1.6

If Sharing
Same Dorm
Room, Go To
4B1.10 INTRO

36

INTRO. 4B1.10
Residence #1

Check if this Residence was a Boarding School or Institution.



If Yes, (4B1.2 = 2 OR 3), SKIP TO QUESTION 4B1.11.
If No, (4B1.2 = 1, 4 OR 5), ASK QUESTION 4B1.10.

If No or Don’t Know
Go To 4B1.11

If No or Don’t Know
Go To 4B1.10.2a

37

If No or Don’t Know
Go To 4B1.10.3a

If No or Don’t Know
Go To 4B1.10.4a

If No or Don’t Know
Go To 4B1.11

38

If No or Don’t Know,
Go To 4B2.1

Go To “Check Response Instruction” following Section 4B1.11.4
If No or Don’t Know,
Go To 4B1.11.2a

39

If No or Don’t Know,
Go To 4B1.11.3a

If No or Don’t Know,
Go To 4B1.11.4a

If No or Don’t Know,
Go To 4B2.1

40

CHECK RESPONSE in Q4A.4 (end year). if this response indicates that respondent was
less than 18 years old, repeat this section for the next residence.
If respondent was age 18 or older when he/she moved out of this house,
Go to Q4C INTRO.

41

4C4.1 INTRO

Longest Adult
Residence Address #1

Start Year

End Year

If 500,000 or more,
Go to 4C4.3

42

If No,
Go to 4C4.10

If No,
Go To 4C5.1 INTRO

Repeat this section for the next 2 longest adult residences.

43

44