Medications Inventory

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.

DRAFT

Form Approved
OMB No. 0920-0904
Exp. Date 08/31/2017

(affix label here)
Patient ID
Number

Site

Sub-site

Sequential ID

SEARCH Medication Inventory (Interviewer Administered)

1. Now I would like to know all of your currently prescribed medication(s), including your insulin and any other diabetes medication.
Are you taking prescribed medication(s)?
Yes If Yes, what prescribed medication(s) are you currently taking? (Interviewer: check all insulins and other diabetes medications and

write the name of any other medication).

No
2. Thank you. Now, for each medication(s) that you just told me about, please let me know if you have taken it in the past two days.

(Interviewer: review the medication(s) reported and check yes or no).
Insulin Medications






Have you taken in last 2 days?

(Check yes or no)

Aspart (Novolog) …………………………..

 Yes

 No

Lispro (Humalog, Humulin H) …………

 Yes

 No

Regular (Novolin R, Humulin R) ……..

 Yes

 No

NPH (Novolin N, Humulin N) ………….

 Yes

 No

 Glargine (Lantus) ………………………………..  Yes

 No

 Yes

 No

 Yes

 No

 Yes

 No

 Premixed insulins (70/30, 75/25, 50/50)
 Other insulin (please write in
medication name below) …………….
_____________________________
 Other injectable medications (please

write in medication name below) ……

______________________________

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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 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).
SEARCH 4 Registry Study - Medications Inventory Form 11-01-10

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Oral Medications for diabetes

Have you taken in last 2 days?

 Metformin (Glucophage) …………………

 Yes

 No

 Acarbose (Precose, Prandase) ………..

 Yes

 No

 Glimepiride (Amaryl) ……………………..

 Yes

 No

 Glipizide (Glucotrol) ……………………….

 Yes

 No

 Glyburide (Micronase, Diabeta,
Glynase) .........................................

 Yes

 No

 Pioglitazone (Actos)..........................

 Yes

 No

 Repaglinide (Prandin) .......................

 Yes

 No

 Rosiglitazone (Avandia) ....................

 Yes

 No

 Rosglitazone/Metformin (Avandamet)

 Yes

 No

 Nateglinide (Starlix) .........................

 Yes

 No

(Check yes or no)

Other Medications (including diabetes medications not listed above)

Have you taken in last 2
days? (Check yes or no)

1

 Yes

 No

2

 Yes

 No

3

 Yes

 No

4

 Yes

 No

5

 Yes

 No

SEARCH 4 Registry Study - Medications Inventory Form – 11-01-10

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Page 2 of 3

6

 Yes

 No

7

 Yes

 No

8

 Yes

 No

9

 Yes

 No

10

 Yes

 No

FOR STUDY USE ONLY
Date
Completed
Date
Reviewed
Date
Entered

Completed by
Month

Day

Year

Reviewer Code
Month

Month

Day

Day

Year

Year

SEARCH 4 Registry Study - Medications Inventory Form – 11-01-10

Data Entry
Code

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