23.6 Survey

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

GENERAL PROGRAMMER INSTRUCTIONS: 1

BIOSPECIMEN TEETH COLLECTION SAQ SPECIFICATION 3

FOR OFFICE USE ONLY: 5

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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.