Form 0920-0906 Appndx D8_6_12mo_FU_Env 7-1-2011

The Green Housing Study

Appndx D9_6_12mo_C7-12 7-1-2011

Six and Twelve Month Follow-up Questionnaire - for Children With Asthma

OMB: 0920-0906

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Green Housing Study ID# ______________

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

House ID# _____________







Green Housing Study







6 and 12-month Follow-up Questionnaire

(Children 7-12 with Asthma)





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 (0920-0906)


Interviewer Initials _______ Date: ___________


1. Observation point (Circle One):


  1. 6-month follow-up (post-remediation)

  2. 12-month follow-up (post-remediation)


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

If yes, please specify

  1. Childcare facility

  2. Private residence

  3. Both


Health Care Access

3. 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:


3.1 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


4. 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


Asthma History


5. 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 14,regular schedule of medicine”

If YES, how many asthma episodes or attacks?

5.1 ______ Number of times


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

Yes No

If NO, Skip to Question #8


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


If child went to Emergency department (6.1 is one or more visits), then ask:



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

If YES, how many times?

6.4.1 ____ Number of times



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

Yes No

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

7.1 ____ Number of visits


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


7.2 ____ Minimum number of days in hospital


7.3 ____ Maximum number of days in hospital


7.4 ____ Total number of days in hospital


8. 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?

8.1.1_____ Number of days [Child’s name] missed school

[Include only days school was in session.]



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


If YES, how many times?

8.2.1_____ Number of days [Child’s name] missed school

[Include only days school was in session.]


9. 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


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


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


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


If YES, then ask

9.2.1_____ Number of days you missed work (if applicable)


9.2.2_____ Number of days you missed other activities


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

Yes No

If YES, then ask

10.1 ______ Number of nights (use your best guess)


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


If YES, then ask


10.2.1 ______ Number of nights


11. 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:

11.1 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)

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


12. 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:

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

1. ≤ 1 month

2. 2 months

3. 3 months

12.2 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)

12.3 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)

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


13. 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)

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


14. 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)

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




15. 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)

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


15.1.2 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


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



  1. Pneumonia Y N DK ______

  2. Bronchitis Y N DK ______


Enter frequency by circling one choice

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

Never Once/Twice Monthly Weekly Daily

  1. Wheezing Never Once/Twice Monthly Weekly Daily

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

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



16. 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:





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

3


File Typeapplication/msword
File Title2008 Behavioral Risk Factor Surveillance System Questionnaire (English version)
Subject2008 Behavioral Risk Factor Surveillance System Questionnaire (English version)
AuthorCDC
Last Modified ByCDC User
File Modified2014-03-06
File Created2014-03-04

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