Form 0920-0906 Appndx D6_Txt_Msg_C7-12 7-1-2011

Green Housing Study Form Approved

OMB No. 0920-0906

Child’s ID# _______________

Appendix D6 Text Messages (Child 7-12 with Asthma) House ID# _____________

Green Housing Study

Text messages (Children 7-12 with Asthma)

1. During the past month, has [Child’s name] had at least 3 of the following: feverish, stuffy/runny nose, cough, sore throat, body aches or tiredness, for more than 24 hours)?

Yes No DK

2. During the past month, did [Child’s name] have an episode of asthma or an asthma attack?

Yes No DK

3. During the past month, did [Child’s name] have an emergency or urgent care visit because of asthma attack?

Yes No DK

Public reporting burden of this collection of information is estimated to average 1 minute 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).