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pdfForm Approved
OMB No. 0920-0904
Exp. Date 11/30/2014
N
W
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SEARCH
For Diabetes in Youth
* Note: Fonts are Times New Roman & Smudger LET Plain.
Initial Participant Survey
Parent / Guardian Version
This survey is to be filled out by the Parent
or legal Guardian of the child age less than
18 years old who has diabetes.
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 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 Reports
Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA (0920-0904)
SEARCH 3 Registry Study — Initial Participant Survey (Parent / Guardian Verison) revised 5-14-12
SEARCH for Diabetes in Youth
This survey is to be filled out by the PARENT or LEGAL GUARDIAN.
We want to learn more about children and young people who have diabetes.
You can help us to do that by filling out these questions. In this survey, we
will use the term CHILD to refer to YOUR CHILD or the child that you are the
LEGAL GUARDIAN for.
1. What is today’s date? ______ /______ /___________
Month
Day
Year
For example, if today is May 1, 2011, write in 05/01/2011
1q
Female 2 q Male
2.
What is your child’s sex?
3.
Has your doctor or nurse ever told you or your child that your child has diabetes?
1q
YES. Turn the page and continue on to question 4.
2q
NO. STOP. Please turn to page 9 and complete this information.
Please mail the survey to us in the stamped envelope.
Thank You
for filling out these questions.
1
We would like to ask you some questions about your child’s birthday, when your
child first got diabetes, and how you or your child takes care of his/her diabetes.
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Please answer the questions as best as you can. If you do not know the answer to a
question, leave it blank.
4. What is your child’s birthdate? ______ /______ /___________
Month
Day
Year
5.
6.
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When was your child first told by a doctor or a nurse that he/she had diabetes?
This means when your child was told about his/her diabetes diagnosis.
______ /______ /___________
Month
Day
Year
How did you first find out that your child had diabetes?
(Check Yes or No for each question)
Yes
No
1q
2q
Yes
No
1q
2q
Yes
2 No
1q
q
Yes
No
1q
2q
Yes
No
1q
2q
My child was thirsty, had to pee a lot, or got sick very quickly.
I found out that my child had diabetes when he/she had a school
physical or at a regular check-up.
I found out that my child had diabetes when his/her blood sugar was
checked at a health fair or at school.
SEF
I found out that my child had diabetes when she was pregnant and the
diabetes did not go away after the pregnancy.
I found out that my child had diabetes when she was pregnant but the
diabetes went away after the pregnancy.
If none of the above apply to you, please write on the lines below how you first found out your child
had diabetes.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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7.
* Note:
What type of diabetes did the doctor or nurse tell you or your child that he/she
has?Fonts are Times New Roman
(please check one box)
1q
Type 1 diabetes, IDDM, juvenile diabetes
2q
Type 2 diabetes, NIDDM
3q
Maturity onset diabetes of youth (MODY)
4q
Other type of diabetes, please specify ___________________________________________
5q
Don’t know
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8.
Has a doctor or nurse told you or your child that his/her diabetes was caused by:
(please check Yes or No for each question)
8a. cystic fibrosis?
8b. cancer or medicine to treat cancer?
8c. another medicine?
1q
E
Yes
2q
Yes
1q
No
2q
1q
Yes
2q
No
No
If Yes, what was the medicine?
9.
Has your child ever taken insulin?
9a. Was he/she taking insulin two weeks after diagnosis?
9b. Is he/she taking insulin now?
1q
Yes
1q
2q
Yes
2q
No (If No, skip to question 10)
1q
Yes
2q
No
No
10. How else does your child take care of his/her diabetes now? Does he/she use:
(please check Yes or No for each question)
SEARCH
For Diabetes in Youth
10a. Diabetes tablets (pills)?
10b. Diet (meal plans)?
10c. Exercise?
10d. Any treatments other than insulin, pills, diet, or exercise: (what?)
1q
1q
Yes
1q
Yes
2q
Yes
2q
2q
No
No
No
11. Is your child Spanish/Hispanic/Latino?
(Mark X in the “No” box if not Spanish/Hispanic/Latino)
q No, not Spanish/Hispanic/Latino
q Yes, Puerto Rican
q Yes, Mexican, Mexican Am., Chicano q Yes, Cuban
q Yes, other Spanish/Hispanic/Latino – Print group:
12. What is your child’s race? Mark one or more races to indicate what your child considers himself/
herself to be.
q White q Black, African American
q American Indian or Alaska Native; Print name of enrolled or principal tribe:
w Roman & Smudger LET Plain.
q Asian Indian
q Japanese
q Native Hawaiian
q Chinese
q Korean
q Guamanian or Chamorro
q Filipino
q Vietnamese
q Samoan
q Other Asian; Print race:
q Other Pacific Islander; Print race:
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13. When your child first got diabetes, where did he/she live?
City
State
Zip Code
County
14. When your child first got diabetes, was he/she in the Army, Navy, Air Force, Marines or
Coast Guard?
1q
Yes
2q
No
3q
Don’t know
Now we have some questions about your child’s current height and weight.
15. What is your child’s current weight?
____________ Pounds,
or ____________ Kilograms
16. What is your child’s current height?
____________ Feet ____________ Inches
q Don’t know
or ____________ Centimeters
q Don’t know
Now we would like to ask you a few questions about whether or not other people in your
child’s family have diabetes.
Please provide information about the child’s mother, father, brothers, and sisters. This refers to the
child’s biological or natural parents (not step-parents or adoptive parents) and the child’s full or half
brothers and sisters, not those who were adopted or step brothers or step sisters.
Please include information for relatives who are living and those who are deceased.
17. Does the child’s biological mother have diabetes?
17a.
1q
Yes
2q
No
3q
Don’t know
q If Yes, how old was she when she was diagnosed with diabetes?
_______ years q Don’t know
18. Did the child’s biological mother have any form of diabetes when she was pregnant with the child?
This includes Type 1 diabetes, Type 2 diabetes, gestational diabetes, or other types of diabetes.
1q
Yes
2q
No
3q
Don’t know
19. Does the child’s biological father have diabetes?
19a.
4
1q
Yes
2q
No
3q
Don’t know
q If Yes, how old was he when he was diagnosed with diabetes?
_______ years q Don’t know
SEARCH for Diabetes in Youth
20. Does the child have any full or half brothers?
1q
(If No or Don’t know, skip to question 21)
2q
No
3q
Don’t know
20a. If Yes, how many full or half brothers does your child have?
Yes
_______ brothers
20b. If Yes, how many full or half brothers have diabetes?
_______ brothers
21. Does the child have any full or half sisters?
1q
(If No or Don’t know, skip to question 22)
2q
No
3q
Don’t know
21a. If Yes, how many full or half sisters does your child have?
Yes
_______ sisters
21b. If Yes, how many full or half sisters have diabetes?
_______ sisters
Now we would like to learn a bit about your child’s health insurance and
health care services.
22. What kind of health insurance plan does your child have NOW?
(Answer Yes or No for each question).
22a. Medicaid/Medicare/State-funded/other Federally-funded
22b. Private insurance, through employer
22c. Private insurance, purchased on your own
22d. Military
22e. School-based insurance
22f. Tribe/Indian Health Service
22g. Any other or type unknown
22h. None
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Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
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23. What kind of health insurance plan did your child have when he/she was diagnosed with diabetes?
(Answer Yes or No for each question).
23a. Medicaid/Medicare/State-funded/other Federally-funded
23b. Private insurance, through employer
23c. Private insurance, purchased on your own
23d. Military
23e. School-based insurance
23f. Tribe/Indian Health Service
23g. Any other or type unknown
23h. None
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
24. Who does your child usually go to for most of his/her care related to diabetes?
(Please check only one response).
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1q
Pediatrician
2q
Family practice or internal medicine physician
3q
Pediatric endocrinologist/diabetologist (diabetes specialist)
4q
Adult endocrinologist/diabetologist (diabetes specialist)
5q
Another type of physician
6q
7q
Other health care professional (nurse, nurse practitioner, physician assistant,
certified diabetes educator, or other)
Unsure
The next few questions are related to the education and household income of your family.
25. What is the highest degree or level of school that your child’s mother/guardian and
father/guardian have completed?
Mother/
Father/
guardian guardian
25a. Any education less than a high school graduate, no diploma
or GED
1q
1q
25b. High school graduate, (high school diploma) or equivalent
(for example, GED)
2q
2q
25c. Business/technical school, associate degree (AA, AS) or some
college
3q
3q
25d. Bachelor degree (for example, BA, AB, BS) (4-year)
4q
4q
25e. Master degree (for example MA, MS, MEng, Med., MSW)
5q
5q
25f. Professional or doctorate degree (for example, MD, DDS, JD,
PhD, EdD)
6q
6q
25g. Don’t know
7q
7q
26. Which of these categories best describes the total income of all persons living in the Parent’s/
Guardian’s household for the past 12 months?
(check only one category)
1q
Less than $5,000
6q
$35,000 through $49,999
2q
$5,000 through $11,999
7q
$50,000 through $74,999
3q
$12,000 through $15,999
8q
$75,000 through $99,999
4q
$16,000 through $24,999
9q
$100,000 and greater
5q
$25,000 through $34,999
10 q
Don’t know
27. How many people are living in the Parent/Guardian’s household?
27a. Total number of people ________
27b. Number of children (less than 18) ________
27c. Number of adults ________
Of the number of adults, how many bring income into the household? ________
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28. Was your child with diabetes born in the United States?
1q
Yes (If Yes, go to question 29)
2q
No
28a. If no, in what country was your child born? Write in country of birth.
28b. In what year did your child come to the United States to live?
3 q Don’t know; prefer not to say
Write in year.
29. Was the child’s mother born in the United States?
1q
Yes
2q
No
29a. If no, in what country was the child’s mother born? Write in country of birth.
q Don’t know country
29b. In what year did the child’s mother come to the United States?
3q
(If Yes, go to question 30)
Write in year.
q Don’t know year
Don’t know; prefer not to say
30. Was the child’s father born in the United States?
1q
Yes
2q
No
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3q
(If Yes, go to next page)
30a. If no, in what country was the child’s father born? Write in country of birth.
q Don’t know country
30b. In what year did the child’s father come to the United States?
q Don’t know year
Don’t know; prefer not to say
Write in year.
Contact Information
We would like to be able to reach you and your child to let you know about other parts of the
SEARCH study. To do this, we would like to have the best address and phone number where we can
reach you and your child.
A.
What is your child’s name?
First Name
Middle Name
Last Name
Are there any other names that he / she uses?
Other first names
Other last names
B.
What are your child’s parent / guardian’s names?
First Name
Middle Name
Last Name
First Name
Middle Name
Last Name
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C.
What is the best address, email and phone number to send mail or call?
P.O.Box
City
State
Email address
Street
Apt#
Zip
Phone number (best)
-
-
area code
Is this:
extension
q Home q Work q Cellular Phone q Other
Phone number (other)
-
-
area code
Is this:
q
extension
Home
Phone number (other)
q
Work
-
q
Cellular Phone
-
area code
Is this:
q
Other
extension
q Home q Work q Cellular Phone q Other
What is the best time to call? q morning
May we contact you over the weekend?
May we contact you at work?
Who lives at this address? (check yes or no for each one)
My child does
1q
Yes
2q
No
Child’s Father
1q
Yes
2q
No
Child’s Mother
1q
Yes
2q
No
Child’s Spouse
1q
Yes
2q
No
Other
1q
Yes
2q
No
Does your child usually speak:
1q
English
2q
Spanish
3q
Some other language
Specify:_______________________________________________________
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q afternoon q evening
q Yes q No
q Yes q No
SEARCH for Diabetes in Youth
Alternate Contact Information
As a part of this study, we may be contacting you in the future. Please provide us with the names,
addresses, phone numbers, and email addresses of two people who could contact you if your
address or phone number changes.
Contact #1:
First Name
Middle Name
Last Name
Relationship
P.O.Box
City
State
Email address
Street
Apt#
Zip Code
Phone number (best)
-
-
area code
Phone number (other)
extension
-
-
area code
Phone number (other)
-
area code
SEARCH for Diabetes in Youth
extension
-
extension
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Contact #2:
First Name
Middle Name
Last Name
Relationship
P.O.Box
City
State
Email address
Street
Zip Code
Phone number (best)
-
-
area code
Phone number (other)
extension
-
-
area code
Phone number (other)
extension
-
area code
Thank You
for filling out this survey.
Please mail it to us in the stamped,
pre-addressed envelope.
If you have lost the envelope, please
send it to the address below.
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Apt#
-
extension
FOR STUDY USE ONLY
Patient ID Number
Site
Sub-site
Sequential ID
Date Completed
Month
Day
Year
Mode of Administration
Date Reviewed
Month
In Person
Day
Month
Day
Telephone
Mailed
CATI
Reviewer Code
Year
Date Entered
Completed by
Data Entry Code
Year
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SEARCH for Diabetes in Youth
* Note: Fonts are Times New Roman & Smudger LET Plain.
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11-0457 search form english parent
| File Type | application/pdf |
| File Modified | 2012-08-28 |
| File Created | 2012-08-21 |