1.4 Survey

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

AdultBloodPreScreeningInstrument

Adult-Focused Biospecimen Collection (Prenatal)

OMB: 0925-0593

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OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Adult Blood Pre-Screening Instrument

OMB Specification


Adult Blood Pre-Screening Instrument


Event Category:

Trigger-Based, Pre-Preg, PV1, PV2; Time-Based, Birth, 6M, 12M, 36M, 60M

Event:

Pre-Preg, PV1, PV2, Birth, 6M, 12M, 36M, 60M

Administration:

N/A

Instrument Target:

Pre-Pregnant Woman; Pregnant Women; Biological Mother; Primary Caregiver

Instrument Respondent:

Pre-Pregnant Woman; Pregnant Women; Biological Mother; Primary Caregiver

Domain:

Biospecimen

Document Category:

Sample Collection

Method:

Data Collector Administered

Mode (for this instrument*):

In-Person, CAI;
Phone, CAI

OMB Approved Modes:

In-Person, CAI;
Phone, CAI

Estimated Administration Time:

2 minutes

Multiple Child/Sibling Consideration:

Per Event

Special Considerations:

N/A

Version:

1.0

MDES Release:

4.0


*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.


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Adult Blood Pre-Screening Instrument



TABLE OF CONTENTS





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Adult Blood Pre-Screening Instrument



GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:


DATA ELEMENT FIELDS

MAXIMUM CHARACTERS PERMITTED

DATA TYPE

PROGRAMMER INSTRUCTIONS

ADDRESS AND EMAIL FIELDS

100

CHARACTER


UNIT AND PHONE FIELDS

10

CHARACTER


_OTH AND COMMENT FIELDS

255

CHARACTER

  • Limit text to 255 characters

FIRST NAME AND LAST NAME

30

CHARACTER

  • Limit text to 30 characters

ALL ID FIELDS

36

CHARACTER


ZIP CODE

5

NUMERIC


ZIP CODE LAST FOUR

4

NUMERIC


CITY

50

CHARACTER


DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)

10

NUMERIC


CHARACTER



  • DISPLAY AS MM/DD/YYYY

  • STORE AS YYYY-MM-DD

  • HARD EDITS:

MM MUST EQUAL 01 TO 12

DD MUST EQUAL 01 TO 31

YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.

TIME VARIABLES

TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION

NUMERIC

  • HARD EDITS:

HOURS MUST BE BETWEEN 00 AND 12;

MINUTES MUST BE BETWEEN 00 AND 59


Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).


POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.



A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.





ADULT BLOOD PRE-SCREENING INSTRUMENT


(TIME_STAMP_ABP_ST).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP

  • PRELOAD PARTICIPANT ID (P_ID) FOR ADULT


ABP01000. I will need to ask you some questions to determine if you are eligible for a blood draw before I schedule a visit for your blood to be drawn.


SOURCE

National Children’s Study, Legacy Phase


ABP02000/(HEMOPHILIA). Do you have hemophilia or any bleeding disorder? 


DATA COLLECTOR INSTRUCTIONS

  • RESPONSE DETERMINES ELIGIBILITY OF STUDY PARTICIPANT FOR BLOOD DRAW.


Label

Code

Go To

YES

1

ABP04000

NO

2


REFUSED

-1

ABP06000

DON'T KNOW

-2

ABP06000


SOURCE

National Children’s Study, Legacy Phase


PROGRAMMER INSTRUCTIONS

  • SET HEMOPHILIA FLAG TO YES IN ODE TABLE IF HEMOPHILIA = 1. [THIS INSTRUCTION IS A PLACEHOLDER UNTIL FLAGS ARE DEFINED AND CREATED]


ABP03000/(CHEMO). Have you had cancer chemotherapy within the past 4 weeks? 


DATA COLLECTOR INSTRUCTIONS

  • RESPONSE DETERMINES ELIGIBILITY OF STUDY PARTICIPANT FOR BLOOD DRAW.


Label

Code

Go To

YES

1

ABP05000

NO

2

ABP08000

REFUSED

-1

ABP06000

DON'T KNOW

-2

ABP06000


SOURCE

National Children’s Study, Legacy Phase


ABP04000. Because you have hemophilia, we will not be able to draw your blood for this study. 


SOURCE

New


PROGRAMMER INSTRUCTIONS

  • GO TO ABP07000.


ABP05000. Because you’ve had chemotherapy recently, we will not be able to schedule a visit to draw your blood at this time. 


SOURCE

New


PROGRAMMER INSTRUCTIONS

  • GO TO ABP07000.


ABP06000. Because you do not know or declined to answer questions about your {hemophilia/chemotherapy status} we will not be able schedule a visit to draw your blood at this time.


SOURCE

New


ABP07000. That’s fine.  Thank you.


SOURCE

New


PROGRAMMER INSTRUCTIONS

  • GO TO COLLECTION_COMMENT


ABP08000. Your responses indicate that you are eligible for a blood draw.  Thank you for your participation.


DATA COLLECTOR INSTRUCTIONS

  • SCHEDULE VISIT FOR PARTICIPANT'S BLOOD DRAW.


ABP09000/(COLLECTION_COMMENT). RECORD ANY COMMENTS ABOUT THE ADULT BLOOD PRE-SCREENING PROCEDURE.


DATA COLLECTOR INSTRUCTIONS

  • DOCUMENT ANY PROBLEMS OR CONCERNS ABOUT THE ADULT BLOOD PRE-SCREENING PROCEDURE.


Label

Code

Go To

NO COMMENTS

1

TIME_STAMP_ABP_ET

COMMENT

2



ABP10000/(COLLECTION_COMMENT_OTH). SPECIFY: ______________________________________________


(TIME_STAMP_ABP_ET).


PROGRAMMER INSTRUCTIONS

  • INSERT DATE/TIME STAMP


Public reporting burden for this collection of information is estimated to average 2 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.

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