Parent-Child Follow-Up Enrollment Form - English

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:______________________________________)

2. What is your birthdate?

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

D D M M M Y Y Y Y

3. 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

4. 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].

5. Does [Child’s name] live with you?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refused

6. 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.

7. 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

8. 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

9. 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.

10. 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

11. 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: ____________ ____________________________)

12. 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

13. 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.

14. 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

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

            Name: _________________________________________    ₇₇ Don’t know    ₈₈ Refused

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

21. 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.

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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.

31. 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

32. 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

33. 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.

34. 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).