Illness checklist - Chinese

Green Housing Study Form Approved

OMB No. 0920-XXXX

Appendix D9 –Illness Checklist (Child 7-12 with asthma)

Child’s ID# ______________

Household ID# _____________

Instructions:

指示：

If child (who is participating in this study) develops at least 3 of the following: fever, stuffy/runny nose, cough, sore throat, body aches or tiredness, for more than 24 hours --- please do the following:

如果小孩有持續24小時以上至少以下三种的症狀：發燒，流鼻涕/鼻塞，咳嗽，喉嚨發炎，身體痛或乏力，請做一下事情：

1. Swab the nose and throat of the child using the directions we gave you when we dropped off the swabs.

1．遵照我們給你的指示用棉簽擦拭小孩的鼻子和喉嚨，

1. Refrigerate the swabs

1. 冷藏用過的棉簽

2. Call the study coordinator at 617-384-8854

B 給研究院致電： 617-394-8854

2. Complete the Illness Checklist (next page), and keep an Illness Log

完成病例檢查表（下一頁）並保留一份生病日誌

Public reporting burden of this collection of information is estimated to average 5 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-XXXX)

這個數據收集所造成的回答負擔大約在5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)

ILLNESS CHECKLIST 病理檢查表

		Symptom Checklist症狀列表
		INSTRUCTIONS: Check box for all symptoms experienced. Check “none” if the symptom is absent. 指示：選擇所有發生的症狀。如果無症狀，選擇“無“。
YES (this symptom developed) 是 （該症狀有發生）		Symptoms 症狀	severity rating (see footnote*) 嚴重程度評級（見註解）
	NO (this symptom did not develop) 否 （該症狀沒有發生）		mild 1 輕微 1	moderate 2 中度 2	severe 3 嚴重 3
		General 綜合
		Fever (______°) temp, if known 發燒（____度）如果知道			
		Chills 發冷			
		weakness/tired 虛弱/乏力			
		Lungs肺部
		Coughing 咳嗽			
		Wheezing 喘息			
		difficulty breathing 呼吸困難			
		Stuffy/ runny nose 鼻塞/流鼻涕			
		Sore throat 喉嚨發炎			
		other: _______________其它：			
		Arms, legs, back, neck 四肢，前胸後背
		muscle aches 肌肉痛			
		joint pain 關節痛			
		headache 頭痛			
		other: _______________其它：			

NOTE: To be given to study technician along with nose/throat swabs

注：同時交給研究院鼻子/喉嚨擦拭棉簽樣本

Date first symptom (checked above) started: ____/____/_____ (mm/dd/yyyy)

症狀（以上）發生日期：

Date that mother/primary caregiver swabbed child: ____/____/_____ (mm/dd/yyyy)

照顧人給小孩擦拭日期：

***Nose and throat swabs should be done within 24-36 hours from the beginning of symptoms***

***Do not swab child’s nose/throat after 5 days of the beginning of symptoms***

***鼻子和喉嚨的擦拭應在症狀開始后24-36小時内進行***

***症狀開始5天以後不要進行擦拭***

ILLNESS LOG

生病日誌

Did the child’s asthma get worse during the illness? Yes No

小孩的哮喘在生病期間加重了嗎？ 是 否

Did the child become so ill that he/she had to see the doctor? Yes No

小孩在生病期間看過醫生嗎？ 是 否

Did doctor prescribe Tamiflu or Relenza? Yes No

醫生有開Tamiflu或者Relenza? 是 否

Did doctor prescribe antibiotics? Yes No

醫生有開抗生素嗎？ 是 否

Did the child become so ill that he/she had to be admitted to a hospital for overnight care?

小孩生病期間有住院嗎？

Yes No

是 否

Date when the child was well enough to do usual activities: ____/_____/_____ (mm/dd/yyyy)

小孩重新開始進行日常活動的日期：

1