Form 0920-0906 Appndx D5_Baseline_C7-12 5-10-2011

Green Housing Study ID# _______________

Baseline (Child 7-12 with asthma) House ID# _____________

Green Housing Study

Baseline Questionnaire (Children 7-12 with Asthma)

Public reporting burden of this collection of information is estimated to average 15 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 (0920-0906).

Interviewer Initials _______ Date: ___________

Demographics

1. Is [Child’s name] Hispanic or Latino? Yes No

2. Which one or more of the following would you say is [Child’s name] race?

(Check all that apply)

2.1 White

2.2 Black or African American

2.3 Asian

2.4 Native Hawaiian or Other Pacific Islander

2.5 American Indian or Alaska Native

3. Does [Child’s name] attend childcare? Yes No

If YES, please specify

1. Childcare facility

2. Private residence

3. Both

Health Care Access

4. Is [Child’s name] currently covered by any kind of health insurance or some other health care plan?

Yes No Don’t know

If YES, then ask:

4.1 Which of the following types of health care insurance is it?

(Please circle one)

1. employer or union either through yourself or another family member

2. Medicaid or any government-assistance plan for those with low incomes or a disability

3. TRICARE, VA, or other military health care

4. Indian Health Service

5. Medicare, for people with certain disabilities

6. Any other type of health insurance or health coverage plan

7. Don’t know

5. Do you have one person you think of as your personal doctor or health care provider?

Probe if answer is NO: “Is there more than one, or is there no person who you think of as your personal doctor or health care provider?”

1. Yes, only one

2. More than one

3. No

4. Don’t know

6. Has a doctor or other health professional ever told you that [Child’s name] has allergies?

Yes No Don’t know

7. Does [Child’s name] have any kind of food allergy?

Y N DK

8. How old was [Child’s name] when you were first told by a doctor, nurse, or other health professional that he/she had asthma?

_________ years (insert 0 if less than 1 year)

9. During the past 3 months, did [Child’s name] have any of these conditions?

(If YES to any of the following, enter number of episodes in space provided)

Number

1. Flu or cold Y N DK ______

(Defined by at least 3 of the following: feverish, stuffy/runny nose, cough, sore throat, body aches or tiredness, for more than 24 hours)

(If YES, then ask)

9.1.1 During these illness episodes, did [Child’s name] asthma get worse? Y N DK

9.1.2 Did [Child’s name] receive Tamiflu® or oseltamivir [o sel TAM i veer] or an inhaled medicine called Relenza® or zanamivir [za NA mi veer] to treat this illness?

Y N DK

9.1.3 Was [Child’s name] prescribed antibiotics? Y N DK

2. Pneumonia Y N DK ______

3. Bronchitis Y N DK ______

Enter frequency by circling one choice

4. Sneezing, runny/stuffed nose (without a cold)

Never Once/Twice Monthly Weekly Daily

5. Wheezing Never Once/Twice Monthly Weekly Daily

6. Cough (without a cold) Never Once/Twice Monthly Weekly Daily

7. Shortness of breath Never Once/Twice Monthly Weekly Daily

10. During the past 3 months, has [Child’s name] had an episode of asthma or an asthma attack?

Yes No Don’t know

If NO, then SKIP to Question 19, “Regular schedule of medicines”

If YES, how many asthma episodes or attacks?

10.1 ______ Number of times

11. During the past 3 months, did [Child’s name] have an emergency department or urgent care visit because of asthma? Yes No

If NO, Skip to Question #13

If YES, did [Child’s name] visit the following?

1. Emergency department Y N ____ Number of visits

2. Urgent care center Y N ____ Number of visits

3. Urgent visit to doctor’s office Y N ____ Number of visits

If child went to Emergency department (11.1 is one or more visits), then ask:

11.4 Did [Child’s name] travel by ambulance? Yes No

If YES, how many times?

11.4.1 ____ Number of times

12. During the past 3 months, has [Child’s name] stayed in the hospital overnight because of asthma? (In other words, admitted to hospital; Do not include an overnight stay in the emergency room.)

Yes No

If YES, how many different times was [Child’s name] admitted to the hospital?

12.1 ____ Number of visits

(If # of visits equals 1, then min = max)

12.2 ____ Minimum number of days in hospital

12.3 ____ Maximum number of days in hospital

12.4 ____ Total number of days in hospital

13. During the past 3 months, was [Child’s name] unable to attend school because of asthma? Yes No

If YES, then ask: How many days did [Child’s name] miss school?

13.1.1_____ Number of days [Child’s name] missed school

[Include only days school was in session.]

13.2 Did this occur in the past 2 weeks? Yes No

If YES, how many times?

13.2.1_____ Number of days [Child’s name] missed school

[Include only days school was in session.]

14. During the past 3 months, were YOU unable to attend work or carry out your usual activities because of [Child’s name] asthma?

Yes No

If YES, then ask

14.1 _____ Total number of days (use your best guess)

14.1.1 _____ Of these, how many work days did you miss?

14.2 Did this occur in the past 2 weeks? Yes No

If YES, then ask

14.2.1_____ Number of days you missed work (if applicable)

14.2.2_____ Number of days you missed other activities

15. In the past 3 months, did [Child’s name] wake up at night because of asthma?

Yes No

If YES, then ask

15.1 ______ Number of nights (use your best guess)

15.2 Did this occur in the past 2 weeks? Yes No

If YES, then ask

15.2.1 ______ Number of nights

16. During the last 3 months, did [Child’s name] take medication when he/she had an asthma episode or attack? Y N DK

If YES, then ask the following:

16.1 Please tell me which medicines

(Interviewer: Place a mark in the “Emergency” column next to each identified medicine on the med sheet on the last two pages of this questionnaire)

16.2 Did this occur in the past 2 weeks? Y N DK

17. During the last 3 months, did [Child’s name] take prescription asthma medications by inhaler? Y N DK

If YES, then ask all of the following:

17.1 How long did [Child’s name] take them?

1. ≤ 1 month

2. 2 months

3. 3 months

17.2 Please tell me which medicines

(Interviewer: Place a mark in the “Inhaler” column next to each identified medicine on the med sheet on the last two pages of this questionnaire)

17.3 Please tell me how many canisters were used up in the past 3 months

(Interviewer: Enter number next to each identified medicine on the med sheet on the last two pages of this questionnaire)

17.4 Did [Child’s name] take prescription asthma medications by inhaler in the past 2 weeks? Y N DK

18. During the last 3 months, has [Child’s name] taken any prescription medicine in pill or syrup form for his/her asthma? Y N DK

If YES, then ask the following:

1. Please tell me which medicines

(Interviewer: Place a mark in the “Pill/Syrup” column next to each identified medicine on the med sheet on the last two pages of this questionnaire)

2. Did this occur in the past 2 weeks? Y N DK

19. During the last 3 months, did [Child’s name] take any medicine on a regular schedule everyday for his/her asthma? Y N DK

If YES, then ask the following:

1. What was the medication?

(Interviewer: Place a mark in the “Regular Schedule” column next to each identified medicine on the med sheet on the last two pages of this questionnaire)

2. Did this occur in the past 2 weeks? Y N DK

20. Did [Child’s name] receive a flu shot (probe: or seasonal flu vaccine?) during the past year?

Y N DK

Emergency/rescue	Inhaler/ nebulizer	Pill/Syrup	Regular (Daily-use) schedule	# Canisters used in last 3 months	Visual Confirmation		Emergency/rescue	Inhaler/ nebulizer	Pill/Syrup	Regular (Daily-use) schedule	# Canisters used in last 3 months	Visual Confirmation
						Accolate							Nedocromil
						Acetaminophen							Pediapred
						Advair							Prednisolone
						Advil							Prednisone
						Aerobid							Proventil
						Aerolate							Pirbuterol
						Aerospan HFA							Primatene Mist
						Albuterol							Pro-Air HFA
						Allegra							Proventil
						Alupent							Pulmicort Turbuhaler
						Asmanex							QVAR
						Atrovent							Respid
						Azmacort							Robitussin
						Beclomethasone dipropionate							Salbutamol
						Beclovent							Salmeterol
						Bitolterol							Serevent
						Brethaire							Singulair
						Brethine							Slo-phyllin
						Budesonide							Symbicort
						Choledyl							Terbutaline
						Claritin							Theo-24
						Combivent							Theochron
						Cromolyn							Theoclear
						Deltasone							Theo-Dur
						Elixophyllin							Theophylline
						Flovent							Theospan
						Flovent Rotadisk							Tilade
						Flunisolide							Tornalate
						Fluticasone							T-Phyl
						Foradil							Triamcinolone acetonide
						Formoterol							Tylenol
						Ibuprophen							Uniphyl
						Intal							Vanceril
						Ipratropium Bromide							Ventolin
						Levalbuterol tartate							Volomax
						Loratidine							Xolair
						Maxair							Xopenex HFA
						Medrol							Zafirlukast
						Metaprel							Zileuton
						Metaproteronol							Zyflo Filmtab
						Methylpredinisolone							Zyrtec
						Montelukast							Other:
						Mometasonefuroate							Other:
						Mucinex							Other:

2

DK = Don’t know R = Refused NA = Not applicable