Screener - Chinese

Green Housing Study Form Approved

Appendix D12 Screening Questionnaire OMB No. 0920-XXX

Household ID #___________

Green Housing Study

綠色住房研究

Screening Questionnaire

審核問卷

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 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXX).

這個數據收集所造成的回答負擔大約在１０分鐘左右，其中包括閲讀指示，搜索現有信息庫，集合和保持所需數據，以及完成並檢查收集的數據。任何單位不能進行或贊助，任何人也沒有必要回答沒有國家管理和經費預算辦公室（OMB）批復編號的數據收集問卷。發送有關回答負擔的評論或者建議到美國疾病控制與方中心(CDC/ATSDR)信息收集審查辦公室：1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXX).

1. What is your date of birth? 你的出生日期是什麽？ _____/_____/_____ (mm月/dd日/yy年)

If mother is younger than 16 years, STOP. This household is not eligible.

如果母親小於１６嵗，到此爲止。這個家庭不合格。

2. How many children with asthma age 7 to 12 (years) do you have? _______

你家裏有多少個患有氣喘的７到１２嵗小孩？　

If answer to Question 2 is Zero (0), then STOP- not eligible. 如果第二題回答為０，到此爲止――不合格。　

If answer to Question 2 is ≥ 1 then ask:如果第二題回答大於或等於一：

How many of your child(ren) with asthma age 7 to 12 (years) meet all of the following criteria?

1. Doctor or healthcare provider ever said that he/she had asthma.

2. Child had asthma symptoms in the past 6 months.

3. Child does not have a medical condition that would make it hard for him/her to participate in the study? (PROBE cystic fibrosis, cerebral palsy)

4. Child sleeps 7 nights per week at this address, on average.

有多少個７到１２嵗患有氣喘的兒童符合下面所有的條件？　

ａ．醫生或醫療提供人明確說過這個孩子有氣喘

ｂ．這個孩子在過去的６個月中出現過氣喘的症狀

ｃ．這個孩子沒有讓他／她不能參加研究的其他健康狀況（提示胞囊纖維症，腦癱等）

ｄ．這個孩子平均每週７天都睡在這個家裏

2.1 Please enter number _______請填入數量＿＿＿＿＿＿

IIf answer to 2.1 is One (1), then this child is eligible, if more than 1, then the youngest child (willing) is eligible. (Please enter the following information for the eligible child)

如果２．１題的答案為一，那麽這個小孩符合條件。如果答案大於一，那麽最小（並願意的）小孩符合條件。（以下請填寫有關符合條件小孩的信息）

2.1.1 What is the child’s date of birth?小孩的出生日期 _____/_____/_____ (mm月/dd日/yy年)

2.1.2 Is this child a girl or boy? 這個小孩是男還是女？(please circle選一) Girl女孩 Boy男孩

IF THIS HOUSEHOLD IS ELIGIBLE, PLEASE COLLECT CONTACT INFORMATION, AND COMPLETE THE CONSENT FORM (and ASSENT FORM IF APPLICABLE)

如果這一家符合條件，請收集聯係信息並完成同意書（如果適合，兒童同意書）

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Contact Information聯係信息

Date _____/_____/_____ (mm/dd/yy)日期 Interviewer’s initials(max 3): ____ ____ ____研究員名字

Study site code研究地編號: _______________________________________ (if code not available, list housing complex如果沒有編號，列出住房群)

NAME OF MOTHER/ PRIMARY CAREGIVER:母親／主要照顧人的名字：

_____________________________________________________ _________________

First名 Last姓 Study ID (mother/ primary caregiver)研究編碼

NAME OF ENROLLED CHILD (AGE 7-12 YEARS WITH ASTHMA):兒童的名字（有氣喘，７到１２嵗）

_____________________________________________________ _________________

First名 Last姓 Study ID (Child with asthma 7-12)研究編碼

What is your relationship to {child’s name}? 你跟這個兒童［兒童名字］是什麽關係？　

1. Mother (BIRTH)　生母

2. Mother (ADOPTIVE/ FOSTER)　養母

3. Mother (STEP)　繼母

4. Father (BIRTH)　生父

5. Father (ADOPTIVE/ FOSTER)養父

6. Father (STEP)繼父

7. Grandmother外婆／奶奶

8. Aunt姨媽／舅媽

9. Uncle姨父／舅舅

10. Grandfather外公／爺爺

11. Other relative其他親戚

12. Unrelated沒有血緣關係

ADDRESS OF HOME: 家庭住址

_____________________________________________________________________________

(Street address街道) (Apt # or Unit #公寓號)

_____________________________________________________________________________

(City市) (State州) (Zip code郵編)

Longitude經度 ____________ Latitude緯度 ______________

Phone number電話號碼: ( ) _________________________

Phone number電話號碼: ( ) ________________________

(Circle one*) H – C – W – O H – C – W – O

*H=home; C=cell; W=work; O=other

E-mail address電子郵件地址:____________________________________________________________________________

Please provide the names and phone numbers of two people who know how to reach you.

(PROBE: We really need this information ONLY if we have tried to contact you several times to set up your appointments).

請提供兩個個可以聯係到你的人的名字和電話號碼。

（提示：這個信息只有在我們在多次都聯係不到你的情況才會用）。

1. Name of alternate contact #1聯係人１的名字:___________________________________________

First名 Last姓

Relationship (Circle one): Parent Sibling Other relative Friend Co-worker Spouse/Partner Other

關係（選一）：家長　兄弟姐妹 其他親戚 朋友 同事 配偶／伴侶 其他

Phone number: ( ) ________________________ Phone number: ( ) ______________________

(Circle one*) H – C – W – O H – C – W – O

電話號碼

2. Name of alternate contact #2聯係人２的名字:________________________________________

First名 Last姓

Relationship (Circle one): Parent Sibling Other relative Friend Co-worker Spouse/Partner Other

關係（選一）：家長　兄弟姐妹 其他親戚 朋友 同事 配偶／伴侶 其他

Phone number: ( ) ________________________ Phone number: ( ) ______________________

(Circle one*) H – C – W – O H – C – W – O

電話號碼