Biometric Measures Ages 3-11

CHILD BIOMETRIC MEASURES (Ages 3-11)

Interviewer_______________ Study ID # - - Date of Completion ___________

Time of Completion___________

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

CHILD BIOMETRIC MEASURES

(Ages 3-11)

Public reporting burden of this collection of information is estimated to average 20 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

Now I'm going to begin with some general questions about your child’s health that relate to the biometric measures we will be collecting today.

PART A.

DEMOGRAPHICS

1.

.	How are you related to (CHILD)? 1. BIOLOGICAL MOTHER (SKIP TO 3) 2. BIOLOGICAL FATHER (SKIP TO 3) 3. ADOPTIVE/STEP/FOSTER/MOTHER (SKIP TO 3) 4. ADOPTIVE/STEP/FOSTERFATHER (SKIP TO 3) 5. PARTNER OF CHILD’S MOTHER OR FATHER 6. GRANDPARENT 7. BROTHER/SISTER (BIOLOGICAL/ADOPTIVE/STEP/IN-LAW/FOSTER 8. AUNT/UNCLE 9. OTHER RELATIVE 10. OTHER NONRELATIVE 11. LEGAL GUARDIAN (SKIP TO 3) 12. CHILD IS WARD OF STATE OR 13. COURT (SKIP TO 3) 97. DON’T KNOW 98. REFUSED
2.Are you (CHILD)’s guardian? 1 Yes 2. No 3. don’t know 4. refused

WEIGHT

3. How do you describe your child’s weight? Would you say:

A. Very underweight

B. Slightly underweight

C. About the right weight

D. Slightly overweight

E. Very overweight

DON’T KNOW

REFUSED

TOBACCO SMOKE/EXPOSURE

4. During the past 7 days, on how many days was your child in the same room with someone who was smoking cigarettes?

0. 0 days

1. 1 or 2 days

2. 3 or 4 days

3. 5 or 6 days

4. 7 days

7. Don’t know

9. Refused

RECENT FOOD INTAKE

5What food or foods did child <> eat during his/her last meal or snack? Please list all the food and drinks you had .List:

5a. what time was that food eaten? ___________________

5b.Is child you currently fasting?

1 Yes
2 No
7 Don‘t know / Not sure
9 Refused

RECENT ILLNESS

6. Please tell me about any cold, flu or other illness your child has had in the last 2 weeks. For each one, please tell me how recently the illness occurred.

If no illness in last 2 weeks, check here: _______

Illness

Today Last 2 days

Last 2 weeks

1) _______________________ □ □ □

2) _______________________ □ □ □

3) _______________________ □ □ □

4) _______________________ □ □ □

5) _______________________ □ □ □

DON’T KNOW

REFUSED

The next few questions will help us understand the results of your child’s saliva sample.

7. Before this visit, when was the last time your child brushed his/her teeth?

Time: __________ AM/PM

DON’T KNOW

REFUSED

8 The last time your child brushed his/her teeth, did he/she see any pink or reddish color when he/she spit into the sink?

Yes

No

DON’T KNOW

REFUSED

9.In the past 24 hours has your child had any injuries to his/her mouth or any dental work that caused bleeding?

Yes

No

DON’T KNOW

REFUSED

10. Does your child have any open sores or cuts in his/her mouth?

Yes

No

DON’T KNOW

REFUSED

10. In the last 24 hours, has {child} lost a tooth?

Yes

No

DON’T KNOW

REFUSED

PART B.

1.

CHILD HEIGHT

MEASURED CM .

RF 9999

2.

CHILD WAIST CIRCUMFERANCE

MEASURED CM... .

RF 9999

3.

CHILD WEIGHT

MEASURED KG... .

RF 9999

4.

5.

SALIVA SAMPLE COLLECTED

YES/NO

5a.

SALIVA SAMPLE #

ID - -

5b.

SALIVA SAMPLE SHIPPING #

ID - -

6. CHILD ACCELEROMETRY STUDY PARTICIPANT?

YES/NO

6a. ACCELEROMETER ID #

ID - -

Version 10-11 PDA Page 5 of 5