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pdfDRAFT FORM
OMB No.
Exp. Date:
N
W
E
Office Use PID: _______________________________ Inc/Prev. Year_______________________________
SEARCH
For Diabetes in Youth
* Note: Fonts are Times New Roman & Smudger LET Plain.
Initial Participant Survey
Parent / Guardian Version
This survey is to be filled out by a Parent or
legal Guardian of the child age less than 18
years old who has diabetes.
Your answers will be kept confidential and
will be used for study purposes only.
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 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 Reports
Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA (0920-0904)
Privacy Act Statement
The information you are being asked to provide is authorized to
be collected under Section 301 of The Public Health Service Act
(42 USC 241). Providing this information is voluntary. CDC will
use this information in its study, SEARCH for Diabetes in Youth,
in order to: (1) Assess the incidence and prevalence of diabetes
among youth in the U.S. by diabetes type, and by demographics
including age, sex, and race/ethnicity; and (2) Assess temporal
trends in diabetes incidence in major US racial/ethnic groups,
including African Americans, Hispanics, American Indian Tribes,
Asian Americans, Pacific Islanders, by age, sex, and diabetes
type. This information will be shared with third party clinical
entities with whom CDC has entered into an Agreement to assist
with carrying out this Study.
SEARCH Registry Study - Prevalent Initial Participant Survey (Parent / Guardian Verison) revised 3-22-16
SEARCH for Diabetes in Youth
We want to learn more about children and young adults who have
diabetes, and how diabetes affects their lives. You can help us learn more
by answering the following questions. In this survey, we will use the term
CHILD to refer to YOUR CHILD that has diabetes..
1.
What is TODAY’S date?
______ /______ /___________
Month
Day
Year
For example, if today is May 1, 2016, write in 05/01/2016
1q
Female 2 q Male
2.
What is your child’s sex?
3.
What is your CHILD’S BIRTHDATE?
______ /______ /___________
Month
4.
Day
Year
Has a doctor or nurse ever told you or your child that your child has diabetes?
1q
YES. Please go to the next page.
2q
NO. STOP. Please turn to page 9 and complete this information.
Please mail the survey to us in the stamped envelope.
Thank You
for filling out these questions.
1
5.
N
When did a doctor or nurse first tell you that your child had diabetes?
This means when your child was told about his/her diabetes diagnosis.
______ /______ /___________
Month
Day
Year
W
6.
Please list all the places your child lived during the year he/she was diagnosed with
diabetes. For example if your child was diagnosed in April 2016, list everywhere he/she
lived from January 2016 through December 2016.
_______________________________________________________________________
City
State
Zip Code
County
_______________________________________________________________________
City
State
Zip Code
County
_______________________________________________________________________
City
State
Zip Code
County
We are going to ask you some questions about when your child first got diabetes, and how
your child’s diabetes is treated. Please answer the questions as best as you can. If you do
not know the answer to a question, leave it blank.
7.
How did you first find out that your child had diabetes?
(Check Yes or No for each question)
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
S
I found out that my child had diabetes because my child was thirsty,
had to pee a lot, or got sick very quickly.
I found out that my child had diabetes at a yearly physical or check-up
with his/her regular doctor.
I found out that my child had diabetes when his/her blood sugar was
checked at a health fair or by a school nurse.
I found out that my child had diabetes when she was pregnant and the
diabetes did not go away after the pregnancy.
If none of the above apply to you, please write on the lines below how you first found out your child
had diabetes.
________________________________________________________________________________________
* Note: Fonts are Times New Rom
________________________________________________________________________________________
________________________________________________________________________________________
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SEARCH for Diabetes in Youth
N
8.
Has a doctor or nurse told you or your child that his/her diabetes was caused by:
(please check Yes or No for each question)
8a. Cystic fibrosis?
8b. Cancer or medicine to treat cancer?
8c. Another medicine?
9.
E
1q
Yes
1q
2q
Yes
No
2q
1q
Yes
2q
No
No
If Yes, what was the medicine?______________________________________________
Since being diagnosed with diabetes, has your child ever taken insulin?
1q
Yes
2q
No (If No, skip to question 10)
9a. Was he/she taking insulin two weeks after diagnosis?
9b. Is he/she taking insulin now?
1q
Yes
2q
SEARCH
For Diabetes in Youth
1q
Yes
2q
No
2q
No
No
10. How else does your child take care of his/her diabetes now?
Does he/she: (please check Yes or No for each question)
10a. Take prescribed tablets (pills) for diabetes?
10b. Follow a diet/meal plan (for example, carbohydrate counting)?
10c. Follow an exercise program?
10d. Any treatments other than insulin, pills, diet, or exercise: (If yes, please list below.)
________________________________________________________________________
________________________________________________________________________
1q
Yes
2q
1q
Yes
1q
Yes
2q
No
No
11. Who does your child usually see for most of his/her care related to diabetes?
(Please check only one response).
1.
q Pediatrician
2. q Family practice or internal medicine physician
3. q Pediatric endocrinologist/diabetologist (diabetes specialist)
4. q Adult endocrinologist/diabetologist (diabetes specialist)
5. q Another type of physician
6. q Other health care provider (nurse, nurse practitioner, physician assistant,
certified diabetes educator, or other)
7. q Unsure
man & Smudger LET Plain.
8. q No current health care provider
SEARCH for Diabetes in Youth
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Now we would like to learn a bit about your child’s health insurance
12. What kind of health insurance plan did your child have when he/she was DIAGNOSED with
diabetes? And what kind of health insurance plan does your child have NOW?
(Please answer Yes or No for each question for insurance at time of DIAGNOSIS and NOW)
HEALTH INSURANCE TYPE
Health Insurance at
TIME OF DIAGNOSIS
Health Insurance
NOW
YES
NO
YES
NO
12a. Medicaid/Medicare
1q
2q
1q
2q
12b. Private insurance, through employer
1q
2q
1q
2q
12c. Private insurance, purchased on your own
1q
2q
1q
2q
12d. Private insurance, purchased through the health
insurance exchange or marketplace
1q
2q
1q
2q
12e. Military
1q
2q
1q
2q
12f. School or college-based insurance
1q
2q
1q
2q
12g. Tribe/Indian Health Service
1q
2q
1q
2q
12h. Any other or type unknown
1q
2q
1q
2q
12i. No health insurance
1q
2q
1q
2q
13. Is your child Spanish/Hispanic/Latino? (Mark X in the “No” box if not Spanish/Hispanic/Latino)
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q No, not Spanish/Hispanic/Latino
q Yes, Puerto Rican
q Yes, Mexican, Mexican American, Chicano
q Yes, Cuban
q Yes, other Spanish/Hispanic/Latino – Print group in the space below:
__________________________________________________________
SEARCH for Diabetes in Youth
14.
What is your child’s race? Mark one or more races to indicate what your child considers himself/
herself to be.
q White q Black, African American
q American Indian or Alaska Native; Print name of enrolled or principal tribe below:
____________________________________________________________________
q Asian Indian
q Japanese
q Native Hawaiian
q Chinese
q Korean
q Guamanian or Chamorro
q Filipino
q Vietnamese
q Samoan
q Other Asian; Print race:_______________________________________________
q Other Pacific Islander; Print race:_______________________________________
15.
What is the highest degree or level of school that your child’s parent/guardian #1 and parent/
guardian #2 have completed?
Parent /
Guardian #1
Parent /
Guardian #2
15a. Any education less than a high school graduate, no
diploma or GED
1q
1q
15b. High school graduate, (high school diploma) or
equivalent (for example, GED)
2q
2q
15c. Business/technical school, associate degree (AA, AS)
or some college
3q
3q
15d. Bachelor degree (for example, BA, AB, BS) (4-year)
4q
4q
15e. Master degree (for example MA, MS, MEng, Med.,
MSW)
5q
5q
15f. Professional or doctorate degree (for example, MD,
DDS, JD, PhD, EdD)
6q
6q
15g. Don’t know
7q
7q
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16. Which of these categories best describes the total income of all persons living in the Parent’s/
Guardian’s household for the past 12 months? (Income could be from salaries, social security,
retirement, Medicaid, disability, alimony, child support, etc.)
Check only one category:
1. q Less than $5,000
6.
q $35,000 through $49,999
7. q $50,000 through $74,999
8. q $75,000 through $99,999
9. q $100,000 and greater
10. q Don’t know
2. q $5,000 through $11,999
3. q $12,000 through $15,999
4. q $16,000 through $24,999
5. q $25,000 through $34,999
17. How many people are currently living in the Parent’s/Guardian’s household?
17a. Total number of people ______
17b. Number of children (less than 18 years)_____
17c. Number of adults_____
17d. Please mark which adults live in the household
YES
NO
Child’s mother
q
q
Child’s father
q
q
Child’s guardian
q
q
Other adult(s)
q
q
Now we would like to ask you a few questions about whether or not other people in your
child’s family have diabetes.
Please provide information about the child’s mother, father, brothers, and sisters. This refers to the
child’s biological or natural parents (not step-parents or adoptive parents) and the child’s full or half
brothers and sisters, not those who were adopted or step brothers or step sisters.
Please include information for relatives who are living and those who are deceased.
18. Does your child’s biological mother have diabetes?
18a.
1q
Yes
2q
No
3q
Don’t know
q If Yes, how old was she when she was diagnosed with diabetes?
_______ years q Don’t know
19. Did your child’s biological mother have any form of diabetes when she was pregnant with the child?
This includes Type 1 diabetes, Type 2 diabetes, gestational diabetes, or other types of diabetes.
1q
Yes
2q
No
3q
Don’t know
20. Does your child’s biological father have diabetes?
Yes
2q
No
3q
Don’t know
20a. q If Yes, how old was he when he was diagnosed with diabetes?
6
1q
_______ years
q Don’t know
21.
Does your child have any full or half brothers?
1q
Yes
2q
No
3q
Don’t know
(If No or Don’t know, skip to question 22)
21a. If Yes, how many full or half brothers does your child have?
_______ brothers
21b. If Yes, how many full or half brothers have diabetes?
_______ brothers
22. Does your child have any full or half sisters?
1q
Yes
2q
No
3q
Don’t know
(If No or Don’t know, skip to question 23)
22a. If Yes, how many full or half sisters does your child have?
_______ sisters
22b. If Yes, how many full or half sisters have diabetes?
_______ sisters
23. Was your child with diabetes born in the United States?
1q
Yes (If Yes, go to question 24)
2q
No
23a. If no, in what country was your child born? Write in country of birth.
23b. In what year did your child come to the United States to live?
3q
Write in year.
Don’t know; prefer not to say
SEARCH for Diabetes in Youth
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24. Was your child’s mother born in the United States?
1q
Yes
2q
No
(If Yes, go to question 25)
24a. If no, in what country was the child’s mother born? Write in country of birth.
q Don’t know country
24b. In what year did the child’s mother come to the United States?
Write in year.
q Don’t know year
q Did not come to the United States
3q
Don’t know; prefer not to say
25. Was your child’s father born in the United States?
1q
Yes
2q
No
(If Yes, go to next page)
25a. If no, in what country was the child’s father born? Write in country of birth.
q Don’t know country
25b. In what year did the child’s father come to the United States?
Write in year.
q Don’t know year
q Did not come to the United States
3q
26.
Don’t know; prefer not to say
During the year 2017, list all the places where your child lived.
CITY
STATE
ZIP CODE
COUNTY
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
8
Contact Information
We would like to be able to reach you in the future to provide information about the SEARCH study.
Please provide the best contact information below.
A.
Name of person filling out this form
First Name
Middle Name
Last Name
B.
Relationship to child: __________________________________________________________
C.
What is your child’s name?
First Name
Middle Name
Last Name
Are there any other names that he / she uses?
Other first names
Other last names
D.
Full Name of Parent or Guardian #1 of child (Please note if Parent or Guardian.)
First Name
Middle Name
Last Name
q Parent q Guardian #1
SEARCH for Diabetes in Youth
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E.
Full Name of Parent or Guardian #2 of child (Please note if Parent or Guardian.)
First Name
Middle Name
Last Name
q Parent q Guardian #2
F.
Provide your current address, email and phone number for future contact.?
P.O. Box
Street
Apt#
City
State
Zip Code
Email address
Phone number (best)
area code
Is this:
extension
q Home q Work q Cellular Phone q Other
Phone number (other)
area code
Is this:
extension
q Home q Work q Cellular Phone q Other
Phone number (other)
area code
Is this:
10
extension
q Home q Work q Cellular Phone q Other
SEARCH for Diabetes in Youth
Alternate Contact Information
As a part of this study, we may be contacting you in the future. Please provide us with the names,
addresses, phone numbers and/or email addresses of a relative or friend, someone who would know
how to contact you if your address or phone number changes.
Contact #1:
First Name
Middle Name
Last Name
Relationship to child
P.O. Box
Street
Apt#
City
State
Zip Code
Email address
Phone number (best)
area code
extension
area code
extension
area code
extension
Phone number (other)
Phone number (other)
SEARCH for Diabetes in Youth
11
Contact #2:
First Name
Middle Name
Last Name
Relationship to child
P.O. Box
Street
Apt#
City
State
Zip Code
Email address
Phone number (best)
area code
extension
area code
extension
area code
extension
Phone number (other)
Phone number (other)
Thank You
for filling out this survey.
Please mail it to us in the stamped,
pre-addressed envelope.
12
FOR STUDY USE ONLY
Patient ID Number
Site
Sub-site
Sequential ID
Date Completed
Month
Day
Year
Mode of Administration
Date Reviewed
Month
In Person
Day
Month
Day
Telephone
Mailed
CATI
Reviewer Code
Year
Date Entered
Completed by
Data Entry Code
Year
N
W
E
SEARCH
For Diabetes in Youth
SEARCH for Diabetes in Youth
* Note: Fonts are Times New Roman & Smudger LET Plain.
13
11-0457 search form english parent
| File Type | application/pdf |
| File Modified | 2017-10-13 |
| File Created | 2016-09-22 |