Form 0920-0906 Appndx D12_Ill_Chklst_C7-12 5-10-2011

Green Housing Study Form Approved

OMB No. 0920-0906

Appendix D12 –Illness Checklist

Child’s ID# ______________

Household ID# _____________

Instructions:

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:

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

1. Refrigerate the swabs

2. Call the study coordinator at ###.###.####

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

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)

ILLNESS CHECKLIST

		Symptom Checklist
		INSTRUCTIONS: Check box for all symptoms experienced. Check “none” if the symptom is absent.
YES (this symptom developed)		Symptoms	severity rating (see footnote*)
	NO (this symptom did not develop)		mild 1	moderate 2	severe 3
		General
		Fever (______°) temp, if known			
		chills			
		weakness/tired			
		Lungs
		coughing			
		wheezing			
		difficulty breathing			
		Stuffy/ runny nose			
		Sore throat			
		other: _______________			
		Arms, legs, back, neck
		muscle aches			
		joint pain			
		headache			
		other: _______________			

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

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

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

***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***

ILLNESS LOG

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

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

Did doctor prescribe Tamiflu or Relenza? Yes No

Did doctor prescribe antibiotics? Yes No

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

Yes No

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

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