Form 10.1 Survey

Continuation of National Children's Study Vanguard (Pilot) Study Data Collection: Study Visits through 60-Months and Sibling Birth Enrollment

InfantChildHealthCareLog

Infant & Child Health Care Log

OMB: 0925-0593

Document [docx]
Download: docx | pdf


OMB #: 0925-0593

OMB Expiration Date: 08/31/2014



























Infant and Child Health Care Log


Birth to 6 years old




Shape1 BRING THIS LOG TO ALL HEALTH CARE VISITS. USE THIS LOG FOR ALL STUDY TELEPHONE CALLS AND VISITS.


Save all bottles and containers of medications. Bring to Study visits and have available for telephone calls:

  • Medicines (those prescribed by a health care provider and those bought over-the-counter)

    • Vitamins, minerals, herbs, and any other supplements



Shape4 Childs Last Name Childs First Name Childs Date of Birth: / /

mm dd yyyy

Shape5

Public reporting 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.

Infant and Child Health Care Log



Shape6 This Infant and Child Health Care Log will help you keep track of all your childs visits to doctors or other health care providers from birth to 6 years old. We will ask you about your childs visits whenever we interview you by telephone or in person.


A Health Care Provider can be:

  • Pediatrician or family medicine doctor

  • Specialist (like a surgeon, heart doctor, allergy or skin doctor)

  • Nurse practitioner or physician assistant

  • Nurse

  • Social worker/counselor

  • Other


Health Care Visits can be to:

  • Doctors office, clinic, or health center

  • Emergency room

  • Urgent care center

  • Hospital (inpatient, overnight stay)

  • Some other place The log has two parts:

  1. Health Care Provider Log is to record information about where your child visits the doctor or other health care provider.


  1. Health Care Visit Log is to record information about all of your childs visits to doctors, other health care providers, or an emergency room. This includes overnight hospital stays as well as outpatient visits.


BRING this Infant and Child Health Care Log with you to all of your childs health care and National Childrens Study visits. Also, have it available for all National Childrens Study telephone interviews.


If you forget to bring it with you to a health care visit, please fill it in as soon as possible.


Save all bottles and containers of medications and bring to National Childrens Study visits and have available for telephone calls:

  • Medicines (those prescribed by a health care provider and those bought over-the-counter)

  • Vitamins, minerals, herbs, and any other supplements


Health Care Provider Log Instructions


Shape7 The health care provider is the person who cared for your child at this visit (doctor, nurse, social worker, etc.)



Column 1 A number is listed for each health care provider (For example, 1, 2, 3, 4, etc.). This number will be referred to on the Health Care Visit Log pages.


Shape8 Column 2 Attach the health care providers business card here.



Fill in columns 3–10 only if you have not attached the health care providers business card.



Shape9 Column 3 Write in the name of the health care provider.


Column 4 Check () the box for the type of provider. If it was Other,” write the type of health care provider.


Shape10 Column 5 Check () the box for the type of place where you saw the provider. If it was Other place,” write in the type of place where your child visited the health care provider.


Columns 6–9 Write in the address of the place including city/town, state, and ZIP code.


Column 10 Write in the telephone number of the health care provider including area code.










See the example in the first line of the log on the next page.

After you fill out the Health Care Provider Log, please fill out the Health Care Visit Log.


Inform the National Childrens Study staff when more log pages are needed.


Fill in ONLY if you HAVE NOT attached a business card

1

2

3

4

5

6

7

8

9

10

Health Care Provider Number


Attach Health Care Provider Business Card


Name of Health Care Provider/Clinic/Hospital

Type of Health Care Provider


Type of Place


Street Address


City or Town


State


ZIP

Code


Telephone Number





0






EXAM





Dr. Joe Jones

PLE

  • Pediatrician or family physician

  • Specialist

  • Nurse

practitioner

or physician assistant

  • Nurse

  • Social worker/

counselor

  • Other (specify):

  • Doctors office, clinic, or health center

  • Emergency

room

  • Urgent care

center

  • Hospital

  • Other place

(specify):




400Main Street




Capitol City





MN





56087




937-889-

9275





1



  • Pediatrician or family physician

  • Specialist

  • Nurse

practitioner

or physician assistant

  • Nurse

  • Social worker/

counselor

  • Other (specify):

  • Doctors office, clinic, or health center

  • Emergency

room

  • Urgent care

center

  • Hospital

  • Other place

(specify):










2



  • Pediatrician or family physician

  • Specialist

  • Nurse

practitioner

or physician assistant

  • Nurse

  • Social worker/

counselor

  • Other (specify):

  • Doctors office, clinic, or health center

  • Emergency

room

  • Urgent care

center

  • Hospital

  • Other place

(specify):











3



  • Pediatrician or family physician

  • Specialist

  • Nurse

practitioner

or physician assistant

  • Nurse

  • Social worker/

counselor

  • Other (specify):

  • Doctors office, clinic, or health center

  • Emergency

room

  • Urgent care

center

  • Hospital

  • Other place

(specify):









Shape17 Shape18 Health Care Provider Log


Fill in ONLY if you HAVE NOT attached a business card

1

2

3

4

5

6

7

8

9

10

Health Care Provider Number


Attach Health Care Provider Business Card


Name of Health Care Provider/Clinic/Hospital

Type of Health Care Provider


Type of Place


Street Address


City or Town


State


ZIP

Code


Telephone Number





4



  • Pediatrician or family physician

  • Specialist

  • Nurse

practitioner

or physician assistant

  • Nurse

  • Social worker/

counselor

  • Other (specify):

  • Doctors office, clinic, or health center

  • Emergency

room

  • Urgent care

center

  • Hospital

  • Other place

(specify):











5



  • Pediatrician or family physician

  • Specialist

  • Nurse

practitioner

or physician assistant

  • Nurse

  • Social worker/

counselor

  • Other (specify):

  • Doctors office, clinic, or health center

  • Emergency

room

  • Urgent care

center

  • Hospital

  • Other place

(specify):











6



  • Pediatrician or family physician

  • Specialist

  • Nurse

practitioner

or physician assistant

  • Nurse

  • Social worker/

counselor

  • Other (specify):

  • Doctors office, clinic, or health center

  • Emergency

room

  • Urgent care

center

  • Hospital

  • Other place

(specify):











7



  • Pediatrician or family physician

  • Specialist

  • Nurse

practitioner

or physician assistant

  • Nurse

  • Social worker/

counselor

  • Other (specify):

  • Doctors office, clinic, or health center

  • Emergency

room

  • Urgent care

center

  • Hospital

  • Other place

(specify):









Health Care Provider Log


Fill in ONLY if you HAVE NOT attached a business card

1

2

3

4

5

6

7

8

9

10

Health Care Provider Number


Attach Health Care Provider Business Card


Name of Health Care Provider/Clinic/Hospital

Type of Health Care Provider


Type of Place


Street Address


City or Town


State


ZIP

Code


Telephone Number





8



  • Pediatrician or family physician

  • Specialist

  • Nurse

practitioner

or physician assistant

  • Nurse

  • Social worker/

counselor

  • Other (specify):

  • Doctors office, clinic, or health center

  • Emergency

room

  • Urgent care

center

  • Hospital

  • Other place

(specify):











9



  • Pediatrician or family physician

  • Specialist

  • Nurse

practitioner

or physician assistant

  • Nurse

  • Social worker/

counselor

  • Other (specify):

  • Doctors office, clinic, or health center

  • Emergency

room

  • Urgent care

center

  • Hospital

  • Other place

(specify):











10



  • Pediatrician or family physician

  • Specialist

  • Nurse

practitioner

or physician assistant

  • Nurse

  • Social worker/

counselor

  • Other (specify):

  • Doctors office, clinic, or health center

  • Emergency

room

  • Urgent care

center

  • Hospital

  • Other place

(specify):











11



  • Pediatrician or family physician

  • Specialist

  • Nurse

practitioner

or physician assistant

  • Nurse

  • Social worker/

counselor

  • Other (specify):

  • Doctors office, clinic, or health center

  • Emergency

room

  • Urgent care

center

  • Hospital

  • Other place

(specify):








Health Care Provider Log

Infant and Child Health Care Log



Health Care Visit Log Instructions

Office and Outpatient Visits and Overnight Hospital Stays


Each time your child goes to the doctor or any other health care provider (For example, doctor, nurse, social worker, etc.) or is hospitalized overnight, write down information about the visit on a new line in the Health Care Visit Log.


Please try to fill in columns 1–3 before the visit. If possible, ask your health care provider or the office staff to fill out columns 4–10. If that is not possible, please fill out columns 4–10 at the visit or as soon as possible.


Column 1


Shape31 Shape32 Column 2



Column 3






Shape33 Column 4–6






Column 7




Shape34 Column 8



Column 9








Column 10

Health care visit date (month/day/year).


Write the Health Care Provider number from Column 1 in the Health Care Provider Log.


Check () the reason(s) for the visit and explain if needed. Include office/outpatient visits and overnight hospital stays. For example:

If your child got a well-baby check up, put a check () in the Routine well visit box.


Write in your childs weight, and length or height at the visit. Write in the Head Circumference through age 2. If these measurements were not done, check () Not done.” For example: If your child is 22 inches long at his visit, write in 22 inches.


If your child got an immunization/vaccination/shot during the visit, put a check () in theYES” box and Go to the Immunization/ Vaccination/Shot Log.


If your child gets any test, medication, or treatment during his/her visit, write it here.


Write what the health care provider told you (the diagnosis) at the visit. Include a few key words to describe the event or diagnosis. For example: For a check-up or well child visit, the doctor may have told you that your child is growing normally and is healthy or “has an ear infection.” Write this down in the Diagnosis or Problem column.


Check () the box to show if the office staff filled out the log or if you did. After you report the visit to the National Childrens Study staff, please write in the date you told us about that visit.

Shape35

See the example in the first line of the log on the next page.

Inform the National Childrens Study staff when more log pages are needed.

1

2

3

4

5

6

7

8

9

10




Date of Visit


Health Care Provider Number from Health Care Provider Log




Reason for Visit (check all that apply)




Weight




Length/ Height



Head Circumference (0–2 years)




Immunization/ Vaccination/ Shot

Tests/Medications/ Treatments

(For example, lab tests (blood, urine…), medicines, vitamins, minerals, herbs, supplements, procedures)




Diagnosis or Problem


Completed by Office or Self

Date Reported to National Childrens Study


March 3, 2011


0

  • Routine well visit

  • Sick visit

  • Specialist doctor visit

  • Emergency visit

  • Immunization/vaccination/

shot

  • Follow-up visit

  • Overnight hospital stay

How many nights?

  • Some other reason (explain):

10 lb

pounds

4 oz

ounces


OR


kg kilograms


  • Not done/ don’t know

23 in

inches


OR


cm centimeters


  • Not done/ don’t know

37 in

inches


OR


cm centimeters


  • Not done/ don’t know

  • No

  • Yes


If ‘YES’ then go to Immunization/ Vaccination/ Shot Log

EXA


Lab test (blood)







PLE


Well infant,

good growth and development

  • Office

  • Self

Date:

March 4, 2011



  • Routine well visit

  • Sick visit

  • Specialist doctor visit

  • Emergency visit

  • Immunization/vaccination/

shot

  • Follow-up visit

  • Overnight hospital stay

How many nights?

  • Some other reason (explain):

lb pounds

oz ounces


OR


kg kilograms


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

  • No

  • Yes


If ‘YES’ then go to Immunization/ Vaccination/ Shot Log



  • Office

  • Self

Date:



  • Routine well visit

  • Sick visit

  • Specialist doctor visit

  • Emergency visit

  • Immunization/vaccination/

shot

  • Follow-up visit

  • Overnight hospital stay

How many nights?

  • Some other reason (explain):

lb

pounds

oz ounces


OR


kg kilograms


  • Not done/ don’t know

in

inches


OR


cm centimeters


  • Not done/ don’t know

in

inches



cm centimeters


  • Not done/ don’t know

  • No

  • Yes


If ‘YES’ then go to Immunization/ Vaccination/ Shot Log



  • Office

  • Self

Date:





















Shape41 Shape42 Shape43 M


1

2

3

4

5

6

7

8

9

10




Date of Visit


Health Care Provider Number from Health Care Provider Log




Reason for Visit (check all that apply)




Weight




Length/ Height



Head Circumference (0–2 years)




Immunization/ Vaccination/ Shot

Tests/Medications/ Treatments

(For example, lab tests (blood, urine…), medicines, vitamins, minerals, herbs, supplements, procedures)




Diagnosis or Problem


Completed by Office or Self

Date Reported to National Childrens Study



  • Routine well visit

  • Sick visit

  • Specialist doctor visit

  • Emergency visit

  • Immunization/vaccination/

shot

  • Follow-up visit

  • Overnight hospital stay

How many nights?

  • Some other reason (explain):

lb pounds

oz ounces


OR


kg kilograms


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

  • No

  • Yes


If ‘YES’ then go to Immunization/ Vaccination/ Shot Log



  • Office

  • Self

Date:



  • Routine well visit

  • Sick visit

  • Specialist doctor visit

  • Emergency visit

  • Immunization/vaccination/

shot

  • Follow-up visit

  • Overnight hospital stay

How many nights?

  • Some other reason (explain):

lb pounds

oz ounces


OR


kg kilograms


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

  • No

  • Yes


If ‘YES’ then go to Immunization/ Vaccination/ Shot Log



  • Office

  • Self

Date:



  • Routine well visit

  • Sick visit

  • Specialist doctor visit

  • Emergency visit

  • Immunization/vaccination/

shot

  • Follow-up visit

  • Overnight hospital stay

How many nights?

  • Some other reason (explain):

lb

pounds

oz ounces


OR


kg kilograms


  • Not done/ don’t know

in

inches


OR


cm centimeters


  • Not done/ don’t know

in

inches


OR


cm centimeters


  • Not done/ don’t know

  • No

  • Yes


If ‘YES’ then go to Immunization/ Vaccination/ Shot Log



  • Office

  • Self

Date:


1

2

3

4

5

6

7

8

9

10




Date of Visit


Health Care Provider Number from Health Care Provider Log




Reason for Visit (check all that apply)




Weight




Length/ Height



Head Circumference (0–2 years)




Immunization/ Vaccination/ Shot

Tests/Medications/ Treatments

(For example, lab tests (blood, urine…), medicines, vitamins, minerals, herbs, supplements, procedures)




Diagnosis or Problem


Completed by Office or Self

Date Reported to National Childrens Study



  • Routine well visit

  • Sick visit

  • Specialist doctor visit

  • Emergency visit

  • Immunization/vaccination/

shot

  • Follow-up visit

  • Overnight hospital stay

How many nights?

  • Some other reason (explain):

lb pounds

oz ounces


OR


kg kilograms


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

  • No

  • Yes


If ‘YES’ then go to Immunization/ Vaccination/ Shot Log



  • Office

  • Self

Date:



  • Routine well visit

  • Sick visit

  • Specialist doctor visit

  • Emergency visit

  • Immunization/vaccination/

shot

  • Follow-up visit

  • Overnight hospital stay

How many nights?

  • Some other reason (explain):

lb pounds

oz ounces


OR


kg kilograms


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

  • No

  • Yes


If ‘YES’ then go to Immunization/ Vaccination/ Shot Log



  • Office

  • Self

Date:



  • Routine well visit

  • Sick visit

  • Specialist doctor visit

  • Emergency visit

  • Immunization/vaccination/

shot

  • Follow-up visit

  • Overnight hospital stay

How many nights?

  • Some other reason (explain):

lb

pounds

oz ounces


OR


kg kilograms


  • Not done/ don’t know

in

inches


OR


cm centimeters


  • Not done/ don’t know

in

inches


OR


cm centimeters


  • Not done/ don’t know

  • No

  • Yes


If ‘YES’ then go to Immunization/ Vaccination/ Shot Log



  • Office

  • Self

Date:


1

2

3

4

5

6

7

8

9

10




Date of Visit


Health Care Provider Number from Health Care Provider Log




Reason for Visit (check all that apply)




Weight




Length/ Height



Head Circumference (0–2 years)




Immunization/ Vaccination/ Shot

Tests/Medications/ Treatments

(For example, lab tests (blood, urine…), medicines, vitamins, minerals, herbs, supplements, procedures)




Diagnosis or Problem


Completed by Office or Self

Date Reported to National Childrens Study



  • Routine well visit

  • Sick visit

  • Specialist doctor visit

  • Emergency visit

  • Immunization/vaccination/

shot

  • Follow-up visit

  • Overnight hospital stay

How many nights?

  • Some other reason (explain):

lb pounds

oz ounces


OR


kg kilograms


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

  • No

  • Yes


If ‘YES’ then go to Immunization/ Vaccination/ Shot Log



  • Office

  • Self

Date:



  • Routine well visit

  • Sick visit

  • Specialist doctor visit

  • Emergency visit

  • Immunization/vaccination/

shot

  • Follow-up visit

  • Overnight hospital stay

How many nights?

  • Some other reason (explain):

lb pounds

oz ounces


OR


kg kilograms


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

in inches


OR


cm centimeters


  • Not done/ don’t know

  • No

  • Yes


If ‘YES’ then go to Immunization/ Vaccination/ Shot Log



  • Office

  • Self

Date:



  • Routine well visit

  • Sick visit

  • Specialist doctor visit

  • Emergency visit

  • Immunization/vaccination/

shot

  • Follow-up visit

  • Overnight hospital stay

How many nights?

  • Some other reason (explain):

lb

pounds

oz ounces


OR


kg kilograms


  • Not done/ don’t know

in

inches


OR


cm centimeters


  • Not done/ don’t know

in

inches


OR


cm centimeters


  • Not done/ don’t know

  • No

  • Yes


If ‘YES’ then go to Immunization/ Vaccination/ Shot Log



  • Office

  • Self

Date:

Shape85 Shape86 Infant and Child Health Care Log



Shape87 Immunization/Vaccination/Shot Log Instructions



    • Write in the date of the immunization/vaccination/shot.


    • Shape88 Put a check () in the box of each vaccine(s) given to your child. Ask your childs health care provider to help you to check all of the right boxes.


    • At the bottom of the log, write in if your child had any problems after any of the immunizations, vaccinations, or shots.



See the example in the first line of the log on the next page.


























Contact your childs doctor if your child has any problems after an immunization/vaccination/shot.




Shape89 Immunization/Vaccination/Shot Log


Needles or Injections Needles or Injections



By Nasal

Measles, Mumps, Rubella, and Varicella (MMRV)

Combination Vaccines

Combination Vaccines

Mouth Needle

Mist

















Hepatitis B (Hep B)

Diphtheria, Tetanus, and Pertussis (whooping cough) (DTaP)

H. Influenza Type B (Hib)

Inactivated Polio (IPV)

Pneumococcal Conjugate (PCV7)

DTaP, Hep B, and IPV

Hib and Hep B

DTaP and Hib

DTaP and IPV

DTaP, IPV, and Hib

Varicella (Chickenpox)

Hepatitis A

Meningococcal

1. Palivizumab to prevent RSV (Respiratory Syncytial Virus)

Rotavirus

Influenza (Seasonal “Flu”)

Influenza (Seasonal “Flu”)

Other

DATE OF IMMUNIZATION

March 3, 2011




Measles, Mumps, and Rubella (MMR)

EXAMPLE




XYZ Vaccine












ANY PROBLEMS AFTER A IMMUNIZATION/VACCINATION/SHOT?

Date of the Immunization/Vaccination/Shot

Date You First Noticed the Problem

Describe the Problem













Immunization/Vaccination/Shot Log



Needles or Injections

Needles or Injections


By Mouth



Needle


Nasal Mist




Combination Vaccines


Combination Vaccines





















DATE OF IMMUNIZATION


Hepatitis B (Hep B)


Diphtheria, Tetanus, and Pertussis (whooping cough) (DTaP)


H. Influenza Type B (Hib)


Inactivated Polio (IPV)


Pneumococcal Conjugate (PCV7)


Measles, Mumps, and Rubella (MMR)


Measles, Mumps, Rubella, and Varicella (MMRV)


DTaP, Hep B, and IPV


Hib and Hep B


DTaP and Hib


DTaP and IPV


DTaP, IPV, and Hib


Varicella (Chickenpox)


Hepatitis A


Meningococcal


1. Palivizumab to prevent RSV (Respiratory Syncytial Virus)


Rotavirus


Influenza (Seasonal “Flu”)


Influenza (Seasonal “Flu”)





Other





















































































































































ANY PROBLEMS AFTER A IMMUNIZATION/VACCINATION/SHOT?

Date of the Immunization/Vaccination/Shot

Date You First Noticed the Problem

Describe the Problem













Immunization/Vaccination/Shot Log



Needles or Injections

Needles or Injections


By Mouth



Needle


Nasal Mist




Combination Vaccines


Combination Vaccines





















DATE OF IMMUNIZATION


Hepatitis B (Hep B)


Diphtheria, Tetanus, and Pertussis (whooping cough) (DTaP)


H. Influenza Type B (Hib)


Inactivated Polio (IPV)


Pneumococcal Conjugate (PCV7)


Measles, Mumps, and Rubella (MMR)


Measles, Mumps, Rubella, and Varicella (MMRV)


DTaP, Hep B, and IPV


Hib and Hep B


DTaP and Hib


DTaP and IPV


DTaP, IPV, and Hib


Varicella (Chickenpox)


Hepatitis A


Meningococcal


1. Palivizumab to prevent RSV (Respiratory Syncytial Virus)


Rotavirus


Influenza (Seasonal “Flu”)


Influenza (Seasonal “Flu”)





Other





















































































































































ANY PROBLEMS AFTER A IMMUNIZATION/VACCINATION/SHOT?

Date of the Immunization/Vaccination/Shot

Date You First Noticed the Problem

Describe the Problem























































U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

Centers for Disease Control and Prevention

U.S. ENVIRONMENTAL PROTECTION AGENCY


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