Parent-Child Follow-Up Enrollment Form - English

ZEN Colombia Study: Zika in Pregnant Women and Children in Colombia

Att B9_Parent_Child_Enrollment_Questionnaire_10302017

Parent-Child Enrollment Questionnaire

OMB: 0920-1190

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PARENT’S STUDY ID: __________ -___-______________________

CHILD’S STUDY ID: __________ -___-______________________ Form Approved

OMB No. 0920-1190

Fecha: __ __/__ __ __ /__ __ __ __ Exp. Date 07/31/2019

D D M M M Y Y Y Y


Staff Administered: ___________________________


PARENT-CHILD Enrollment Questionnaire


City: ______________________________________________


Clinic: _____________________________________________


First we have a few questions about you.


  1. What is your relationship to [Child’s name]?


0 Mother

1 Father

2 Legal guardian (Specify relationship:______________________________________)


  1. What is your birthdate?


__ __/__ __ __ /__ __ __ __ 77 Don’t know 88 Refused

D D M M M Y Y Y Y


  1. What is the highest level of education that you have completed?


1 Less than primary 2 Primary 3 Secondary 4 Technical 5 University or more 6 None

77 Don’t know 88 Refused


  1. What is your household’s socioeconomic stratum?


1 1 2 2 3 3 4 4 5 5 6 6 77 Don’t know 88 Refused


Next we are going to ask you about who helps provide care for [Child’s name].


  1. Does [Child’s name] live with you?


1 Yes 0 No 77 Don’t know 88 Refused


  1. How many adults and children live in the same household as [Child’s name], including [Child’s name]?


______ adults (18+ years) ______ children (<18 years) 77 Don’t know 88 Refused


  • If, according to question #6, there are no other children in the household, go to question #8.


  1. How old are each of the other children that live in the household with [Child’s name]?


Age of [Child’s name]:________ (circle: months years )

Age of other child (1):________ years

Age of other child (2):________ years

Age of other child (3):________ years

Age of other child (4):________ years

Age of other child (5):________ years

Age of other child (6):________ years

Age of other child (7):________ years

Age of other child (8):________ years


  1. Please tell me which of the following people have helped provide care for [Child’s name] on a regular basis since [Child’s name]’s birth.


Does this person care for [Child’s name]?

If yes, where?



If yes, on average, how often?

On average, how many children are cared for with [Child’s name]?

On average, how many people are providing care?

Child’s mother

1 Yes

0 No

88 Refused

3 In child’s home

2 In someone else’s home

1 In a childcare center

0 Other: ______________

88 Refused


______ days/week


______ hours/day


______ children


______ people

Child’s father

1 Yes

0 No

88 Refused

3 In child’s home

2 In someone else’s home

1 In a childcare center

0 Other: _____________

88 Refused


______ days/week


______ hours/day


______ children


______ people

Non-parental partner of [Child’s name]’s mother/ father

1 Yes

0 No

88 Refused

3 In child’s home

2 In someone else’s home

1 In a childcare center

0 Other: _____________

88 Refused


______ days/week


______ hours/day


______ children


______ people

Child’s sibling under age 18 (age _______ )


1 Yes

0 No

88 Refused

3 In child’s home

2 In someone else’s home

1 In a childcare center

0 Other: ______________

88 Refused


______ days/week


______ hours/day


______ children


______ people

Child’s sibling over age 18 (age _______ )

1 Yes

0 No

88 Refused

3 In child’s home

2 In someone else’s home

1 In a childcare center

0 Other: ______________

88 Refused


______ days/week


______ hours/day


______ children


______ people

Child’s grandparent

1 Yes

0 No

88 Refused

3 In child’s home

2 In someone else’s home

1 In a childcare center

0 Other: ______________

88 Refused


______ days/week


______ hours/day


______ children


______ people

Other adult relative

1 Yes

0 No

88 Refused

3 In child’s home

2 In someone else’s home

1 In a childcare center

0 Other: ______________

88 Refused


______ days/week


______ hours/day


______

children


______ people

Friend or neighbor

1 Yes

0 No

88 Refused

3 In child’s home

2 In someone else’s home

1 In a childcare center

0 Other: ______________

88 Refused


______ days/week


______ hours/day


______ children


______ people

Unrelated adult (including a professional at a child care center)

1 Yes

0 No

88 Refused

3 In child’s home

2 In someone else’s home

1 In a childcare center

0 Other: ______________

88 Refused


______ days/week


______ hours/day


______ children


______ people

Other (specify:

__________)


1 Yes

0 No

88 Refused

3 In child’s home

2 In someone else’s home

1 In a childcare center

0 Other: ______________

88 Refused


______ days/week


______ hours/day


______ children


______ people


  1. How satisfied are you with the amount of help you receive in caring for [Child’s name]?

5 Very satisfied

4 Somewhat satisfied

3 Not satisfied or unsatisfied

2 Somewhat unsatisfied

1 Very unsatisfied

88 Refused



Now we have questions about any feeding or crying difficulties [Child’s name] may be having.


  1. How often is [Child’s name] hard to feed?


1 All or most of the time

2 Some of the time

3 Rarely

4 Never









  1. Below is a list of things that children sometimes do at meal times. Please tell me how often

you think [Child’s name] does each of these things. Response options include rarely or never, some of the time, or almost always.


Rarely or never0

Some of the time1

Almost Always2

Don’t know77

Refused88

Not Applicable66

Excessive spitting up







Excessive drooling







Gagging/retching/coughing







Difficulty swallowing







Difficulty latching or sucking at breast or bottle







Arching back/squirming away







Refuses to open mouth







Spits food out







Eats too fast







Turns head away from food/shakes head no







Chews/sucks on food but does not swallow







Swallows in “gulps”







Any other feeding difficulties at mealtimes (Specify: ____________ ____________________________)









  1. How many hours per day would you say [Child’s name] cries, on average:

0 <1 hour 1 1-3 hours 2 3-6 hours 3 6-9 hours 4 9-12 hours 5 >12 hours

77 Don’t know 88 Refused


  1. In general, how easy is it to calm [Child’s name] when he or she is crying or fussy? Please only select one answer.

0 Very easy

1 Somewhat easy

2 Somewhat difficult

3 Very difficult

77 Don’t know

88 Refused


Let’s now update our information about [Child’s name]’s healthcare.


  1. What type of health insurance does [Child’s name] have?


1 Contributory     2 Subsidized     3 Not insured   4 Specialized    5 Exception 

6 Indeterminate / independent        77 Don’t know   88 Refused


  1. What is the name of [Child’s name]’s health insurance provider?


            Name: _________________________________________    77 Don’t know    88 Refused

Shape1

Since [Child’s name]’s last study visit, have you:

  1. Taken [Child’s name] to a regular well-child check-up or sought medical care for [Child’s name] because she or he was showing symptoms of being sick (for example, a fever, rash)?

1 Yes

Number of times:____________

Clinic name (1):_______________________________

Clinic name (2):_______________________________

Clinic name (3):_______________________________

Clinic name (4):_______________________________

Clinic name (5):_______________________________

0 No 77 Don’t know 88 Refused


If NO, please skip to Question # 21.

  1. Since [Child’s name]’s last study visit, did [Child’s name] have any of the following tests? Say “yes” or “no” to each one I mention. Did [Child’s name] have a…

Cranial ultrasound

1 Yes (Clinic name:_______________________________)

0 No 77 Don’t know 88 Refused

MRI

1 Yes (Clinic name:_______________________________)

0 No 77 Don’t know 88 Refused

CAT scan

1 Yes (Clinic name:_______________________________)

0 No 77 Don’t know 88 Refused

Hearing test

1 Yes (Clinic name:_______________________________) 0 No 77 Don’t know 88 Refused

Vision test

1 Yes (Clinic name:_______________________________)

0 No 77 Don’t know 88 Refused

Developmental assessment

1 Yes (Clinic name:_______________________________)

0 No 77 Don’t know 88 Refused

Did [Child’s name] have any other tests I didn’t mention?

1 Yes test: _____________________________________

_________________________________________________

Clinic name:_______________________________________)

0 No 77 Don’t know 88 Refused

  1. Since [Child’s name]’s last study visit, did you see a medical specialist?

1 Yes 0 No 77 Don’t know 88 Refused


If YES, what type of medical provider did [Child’s name] see? Say “yes” or “no” to each one I mention. Did [Child’s name] see a…

Pediatrician

1 Yes (Clinic name:_______________________________)

0 No 77 Don’t know 88 Refused

Occupational or physical therapist

1 Yes (Clinic name:_______________________________) 0 No 77 Don’t know 88 Refused

Speech-language specialist

1 Yes (Clinic name:_______________________________)

0 No 77 Don’t know 88 Refused

Neurologist

1 Yes (Clinic name:_______________________________)

0 No 77 Don’t know 88 Refused

Gastroenterologist

1 Yes (Clinic name:_______________________________)

0 No 77 Don’t know 88 Refused

Ophthalmologist


1 Yes (Clinic name:_______________________________)

0 No 77 Don’t know 88 Refused

Audiologist


1 Yes (Clinic name:_______________________________)

0 No 77 Don’t know 88 Refused

Developmental Specialist


1 Yes (Clinic name:_______________________________) (Type of specialist: ________________________________)

0 No 77 Don’t know 88 Refused

Did [Child’s name] see any other type of medical provider I didn’t mention?

1 Yes (Provider type:_______________________________

Clinic name:________________________________)

0 No 77 Don’t know 88 Refused

  1. Since [Child’s name]’s last study visit, has [Child’s name] spent one night or more in the hospital?

1 Yes

Number of times:____________

Hospital name (1):_______________________________

Hospital name (2):_______________________________

Hospital name (3):_______________________________

Hospital name (4):_______________________________

Hospital name (5):_______________________________

0 No 77 Don’t know 88 Refused


  1. Now I will give you a list of conditions. Please say “yes” or “no” if, since [Child’s name]’s last study visit, a healthcare provider told you that [Child’s name] might have this illness. Did they say that [Child’s name] had?

Zika virus

1 Yes 0 No 77 Don’t know 88 Refused

Dengue

1 Yes 0 No 77 Don’t know 88 Refused

Chikungunya

1 Yes 0 No 77 Don’t know 88 Refused

Yellow Fever

1 Yes 0 No 77 Don’t know 88 Refused

Cytomegalovirus

1 Yes 0 No 77 Don’t know 88 Refused

Rubella

1 Yes 0 No 77 Don’t know 88 Refused

Toxoplasmosis

1 Yes 0 No 77 Don’t know 88 Refused

Syphilis

1 Yes 0 No 77 Don’t know 88 Refused

Chicken Pox

1 Yes 0 No 77 Don’t know 88 Refused

Parvovirus

1 Yes 0 No 77 Don’t know 88 Refused

Herpes

1 Yes 0 No 77 Don’t know 88 Refused


Did they tell you [Child’s name] had something else I didn’t mention?


1 Yes, specify: ______________________

0 No 77 Don’t know 88 Refused






  1. Since your last study visit, have you or [Child’s name] enrolled in another Zika virus study?

1 Yes, I did Which study? _______________________________________________

2 Yes, my child did Which study? _______________________________________________

3 Yes, my child and I did Which study? ___________________________________________

0 No

77 Don’t know

88 Refused


Next, we have additional questions about you and your family and friends.


  • If, according to question #1, this participant is the legal guardian, go to question #30.


  1. What was your relationship with [Child’s name]’s father (mother) when he/she was born? Were you:

1 Married

2 Free Union

3 Single

4 Divorced

5 Widowed

6 Other (Specify:_________________________________________________________)

77 Don’t know

88 Refused


  1. When [Child’s name] was born, were you and your baby’s father (mother) living together….

1 All or most of the time

2 Some of the time

3 Rarely

4 Never

88 Refused

66 Not applicable


  1. What is your relationship with [Child’s name]’s father (mother) now? Are you:

1 Married

2 Free Union

3 Single

4 Divorced

5 Widowed

6 Other (Specify:_________________________________________________________)

77 Don’t know

88 Refused








  1. Are you and [Child’s name]’s father (mother) currently living together….

1 All or most of the time

2 Some of the time

3 Rarely

4 Never

66 Not applicable


  1. Are you in a new relationship?

1 Yes, married to a new partner

2 Yes, romantically involved with a new partner

3 No

66 Not applicable


  1. Most people have disagreements in their relationships. Please indicate below the approximate extent of agreement or disagreement between you and your partner for each item on the following list.



Always disagree (0)

Almost always disagree (1)

Frequently disagree (2)

Occasionally Disagree (3)

Almost Always Agree(4)

Always Agree (5)

Refused

(88)

Philosophy of life








Aims, goals, and things believed important








Amount of time spent together










  1. How often would you say the following events occur between you and your mate?



Never (0)

Less than once a month (1)

Once or twice a month (2)

Once or twice a week (3)

Once a day (4)

More often

(5)

Refused

(88)

Have a stimulating exchange of ideas








Calmly discuss something together








Work together on a project









  1. The dots on the following line represent different degrees of happiness on your relationship. The middle point, “happy”, represents the degree of happiness in most relationships. Please circle the response which best describes the degree of happiness, all things considered, of your relationship.


0

1

2

3

4

5

6

88

Extremely unhappy

Fairly unhappy

A little unhappy

Happy

Very happy

Extremely happy

Perfect

Refused



  1. We are interested in how you feel about the following statements. I will read each statement to you. Please indicate how you feel about each statement.



Very strongly disagree (1)

Strongly disagree (2)

Mildly disagree

(3)

Neutral

(4)

Mildly Agree

(5)

Strongly agree

(6)

Very strongly agree

(7)

Refused

(88)

There is a special person who is around when I am in need.









There is a special person with whom I can share my joys and sorrows.









My family really tries to help me.









I get the emotional help and support I need from my family.









I have a special person who is a real source of comfort to me.









My friends really try to help me.









I can count on my friends when things go wrong.









I can talk about my problems with my family.









I have friends who with whom I can share my joys and sorrows.









There is a special person in my life who care about my feelings.









My family is willing to help me make decisions.









I can talk about my problems with my friends.











Now, we have a few questions about any concerns you might have about your financial situation.


  1. How often would you say you worry about having enough money to pay for things you need, such as food, shelter, or clothes for you and your family?


4 Always 3 Often 2 Sometimes 1 Rarely 0 Never 77 Don’t know 88 Refused


  1. Have you ever been unable to pay or delayed payment for medical care, including medications, hospital stays, and doctors' visits?


1 Yes 0 No 77 Don’t know 88 Refused


  1. Was there a time since your last visit when you or someone in your household needed to see a doctor or buy medicine but could not because of cost?


1 Yes 0 No 77 Don’t know 88 Refused


Lastly, we have a few questions about your household environment.


  1. Since your last study clinic visit, has anyone in [Child’s name]’s household done any of the following? Say “yes” or “no” to each option.


Used any pesticides, insecticides, or rat poison in or around your home

1 Yes 0 No 77 Don’t know 88 Refused

Smoked cigarettes inside your home?

1 Yes 0 No 77 Don’t know 88 Refused

Smoked marijuana inside your home?

1 Yes 0 No 77 Don’t know 88 Refused

Used drugs such as crack, cocaine, or heroin?

1 Yes 0 No 77 Don’t know 88 Refused



Thank you for completing this questionnaire. Please let me know if you have any questions.



Page 1 of 19

Appendix F8, version November 1, 2017


CDC estimates the average public reporting burden for this collection of information as 35 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0920-1190).


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