Form 0920-0906 Appndx D7_3_9mo_C7-12 5-10-2011

Green Housing Study ID# ______________

6-month follow-up (Child 7-12 with asthma)

House ID# _____________

Green Housing Study

3 and 9-month Follow-up Questionnaire

(Children 7-12 with Asthma)

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 (0920-0906)

Interviewer Initials _______ Date: ___________

1. Observation point (Circle One):

1. 3-month follow-up (post-remediation)

2. 9-month follow-up (post-remediation)

Respiratory illness

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

(If YES, 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)

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

2.1.2 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

2.1.3 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

3. 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 Contact Information Update

If YES, how many times?

3.1 ______ Number of times

3.2 Did any episode occur in the past 2 weeks? Yes No

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

Yes No

If NO, Skip to Question # 6

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

4.1 Emergency department Y N ____ Number of visits

4.2 Urgent care center Y N ____ Number of visits

4.3 Emergency visit to doctor’s office Y N ____ Number of visits

5. During the past 3 months, has [Child’s name] stayed in the hospital (NOT considering the emergency department) because asthma?

Yes No

If YES, how many times?

5.1 ____ Maximum number of days at the hospital

5.2 Did [Child’s name] need stay in the ICU? Yes No DK

6. 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?

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

[Include only days school was in session.]

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

If YES, how many times?

6.2.1_____ Number of days [Child’s name] missed school

[Include only days school was in session.]

7. 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

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

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

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

If YES, then ask

7.2.1_____ Number of days you missed work (if applicable)

7.2.2_____ Number of days you missed other activities

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

Yes No

If YES, then ask

8.1 ______ Number of nights (use your best guess)

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

If YES, then ask

8.2.1 ______ Number of nights

Contact Information

Telephone numbers: Same New

Home ( ) ______________ ( ) ( )

Work ( ) ______________ ( ) ( )

Cellular ( ) ______________ ( ) ( )

Email address __________________ ( ) ( )

Alternate Contacts

Telephone numbers: Same New Relationship to respondent

Home ( ) ______________ ( ) ( ) ____________________

Work ( ) ______________ ( ) ( ) ____________________

Cellular ( ) ______________ ( ) ( ) ____________________

Email address __________________ ( ) ( ) ____________________

Remind subject to collect nasal and throat swabs and call study coordinator for sample pick up.

Also important to remind subject about keeping an illness log with eventful health outcomes like visit to doctor, hospitalization etc. Also, ask to collect the completed logs.

2

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