23.6 Survey

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

60M_ChildTeethSAQ

Child-Focused Biospecimen Collection (Postnatal)

OMB: 0925-0593

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OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Child Teeth SAQ, Phase 2g

OMB Specification


Child Teeth SAQ


Event Category:

Time-Based

Event:

60M

Administration:

N/A

Instrument Target:

Child

Instrument Respondent:

Primary Caregiver

Domain:

Biospecimen

Document Category:

Sample Collection

Method:

Self-Administered

Mode (for this instrument*):

In-Person, PAPI

OMB Approved Modes:

In-Person, PAPI;
Phone, PAPI;
Web-Based, CAI

Estimated Administration Time:

6 minutes

Multiple Child/Sibling Consideration:

Per Child

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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Child Teeth SAQ



TABLE OF CONTENTS





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Child Teeth SAQ



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.





BIOSPECIMEN TEETH COLLECTION SAQ SPECIFICATION


BTC01000. As part of the National Children’s Study, we are asking you to send us the child’s baby teeth when they fall out. Please follow the instructions provided in the child teeth collection kit to collect the sample.

After you have collected the teeth, please complete the information on this form. ​Only one tooth should be collected for each form completed.


BTC01100/(TOOTH_COLLECT_LOC). Which tooth are you sending? Most children have 10 baby teeth on the lower jaw and 10 baby teeth on the upper jaw. Mark an "X" on the diagram below that matches the tooth being sent.



Label

Code

Go To

UPPER, RIGHT CENTRAL INCISOR

1


UPPER, LEFT CENTRAL INCISOR

2


UPPER, RIGHT LATERAL INCISOR

3


UPPER, LEFT LATERAL INCISOR

4


UPPER, RIGHT CUSPID

5


UPPER, LEFT CUSPID

6


UPPER, RIGHT FIRST MOLAR

7


UPPER, LEFT FIRST MOLAR

8


UPPER, RIGHT SECOND MOLAR

9


UPPER, LEFT SECOND MOLAR

10


LOWER, RIGHT CENTRAL INCISOR

11


LOWER, LEFT CENTRAL INCISOR

12


LOWER, RIGHT LATERAL INCISOR

13


LOWER, LEFT LATERAL INCISOR

14


LOWER, RIGHT CUSPID

15


LOWER, LEFT CUSPID

16


LOWER, RIGHT FIRST MOLAR

17


LOWER, LEFT FIRST MOLAR

18


LOWER, RIGHT SECOND MOLAR

19


LOWER, LEFT SECOND MOLAR

20



SOURCE

New


BTC02000. Enter the date when this tooth fell out:


SOURCE

New


(TOOTH_COLLECT_MM) |___|___|

   M     M


(TOOTH_COLLECT_DD) |___|___|

   D     D


(TOOTH_COLLECT_YYYY) |___|___|___|___|

   Y     Y     Y    Y


BTC03000. How long was the tooth stored before returning it to the NCS using the pre-labeled envelope?


SOURCE

New


(TOOTH_STORED_LENGTH) |___|___| Number


SOURCE

New


(TOOTH_STORED_LENGTH_UNIT)


Label

Code

Go To

Days

1


Weeks

2


Months

3



SOURCE

New


BTC04000. Thank you for participating in the National Children’s Study and for taking the time to complete this information.

 

Please call the Regional Operations Center number located on the last page, if you have any questions.



FOR OFFICE USE ONLY:


FOU01000/(SPECIMEN_ID). Specimen ID:

 

l___l___|___l___l___l___l___l___l___l - l___l___l___l___l


FOU02000/(P_ID). Participant ID:_______________________________


FOU03000/(R_P_ID). Respondent ID:_________________________________


FOU04000/(EVENT_ID). Visit Type/Event ID:________________________________


Public reporting burden for this collection of information is estimated to average 6 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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