Parent Child Enrollment Questionnaire - trkchg

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

PARENT’S STUDY ID: __________ -___-______________________ OMB No. 0920-1190

Date: __ __/__ __ __ /__ __ __ __ Exp. Date 02/28/2021

D D M M M Y Y Y Y

Staff Administered: ___________________________

PARENT-CHILD Enrollment Questionnaire

First we have a few questions about you and your household.

1. What is your relationship to this child?

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

5. Does your child live with you?

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

6. Including you and your child, how many adults and children live in the same household with your child?

______ 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 your child, not including your child enrolled in ZEN?

Age of other child (1):________ years ₇₇ Don’t know ₈₈ Refused

Age of other child (2):________ years ₇₇ Don’t know ₈₈ Refused

Age of other child (3):________ years ₇₇ Don’t know ₈₈ Refused

Age of other child (4):________ years ₇₇ Don’t know ₈₈ Refused

Age of other child (5):________ years ₇₇ Don’t know ₈₈ Refused

Age of other child (6):________ years ₇₇ Don’t know ₈₈ Refused

Age of other child (7):________ years ₇₇ Don’t know ₈₈ Refused

Age of other child (8):________ years ₇₇ Don’t know ₈₈ Refused

Age of other child (9):________ years ₇₇ Don’t know ₈₈ Refused

Age of other child (10):________ years ₇₇ Don’t know ₈₈ Refused

Now we want to learn a bit more about who helps provide care for your child.

8. First, tell me about how often you have provided care for your child since your child’s birth.

1. How many days per week do you provide care for your child?

_______ days/week ₈₈ Refused

2. On days when you provide care for your child, how many hours per day?

_______ hours/day ₈₈ Refused

3. Has someone helped you to provide care for your child on a regular basis since your child’s birth?

₁ Yes ₀ No ₈₈ Refused

• If question #8c is “No”, then go to question #10.

9. Please think about the three people (such as family members or professional caregivers) who have helped provide care for your child on a regular basis most often since your child’s birth, other than you. I will ask you some questions about each of these people.

Person (1)
9a. For the first person you’ve thought of, what is this person’s relationship to your child? I will read you a list of options and please select the best one.	0 Child’s mother 1 Child’s father 2 Non-parental partner of your child’s mother/ father 3 Child’s grandparent 4 Child’s relative under age 18 (including a sibling younger than 18) 5 Other adult relative (including a sibling 18 or older) 6 Friend or neighbor 7 Unrelated adult (including a professional at a child care center) 8 Other 88 Refused 66 Not applicable – I do not have another person who cares for my child (If not applicable, skip to question #10).
	If other, specify:______________________________
9b. Does this person help care for your child in the following locations?
In the child’s home	1 Yes 0 No 88 Refused
In someone else’s home	1 Yes 0 No 88 Refused
In a childcare center/nursey	1 Yes 0 No 88 Refused
Other	1 Yes 0 No 88 Refused
	If other, specify:______________________________
9c. How many days per week does this person help care for your child?	_______ days per week 88 Refused
9d. On days when this person helps care for your child, how many hours per day?	_______ hours per day 88 Refused
9e. On average, how many additional children does this person care for at the same time as your child?	________ children 88 Refused
9f. On average, how many additional people also provide care for your child alongside this person?	________ people 88 Refused
Person (2)
9g. For the second person you’ve thought of, what is this person’s relationship to your child? I will read you a list of options and please select the best one.	0 Child’s mother 1 Child’s father 2 Non-parental partner of your child’s mother/ father 3 Child’s grandparent 4 Child’s relative under age 18 (including a sibling younger than 18) 5 Other adult relative (including a sibling 18 or older) 6 Friend or neighbor 7 Unrelated adult (including a professional at a child care center) 8 Other 88 Refused 66 Not applicable – I do not have another person who cares for my child (If not applicable, skip to question #10).
	If other, specify:______________________________
9h. Does this person help care for your child in the following locations?
In the child’s home	1 Yes 0 No 88 Refused
In someone else’s home	1 Yes 0 No 88 Refused
In a childcare center/nursey	1 Yes 0 No 88 Refused
Other	1 Yes 0 No 88 Refused
	If other, specify:______________________________
9i. How many days per week does this person help care for your child?	_______ days/week 88 Refused
9j. On days when this person helps care for your child, how many hours per day?	_______ hours/day 88 Refused
9k. On average, how many additional children does this person care for at the same time as your child?	________ children 88 Refused
9l. On average, how many additional people also provide care for your child alongside this person?	________ people 88 Refused
Person (3)
9m. For the third person you’ve thought of, what is this person’s relationship to your child? I will read you a list of options and please select the best one.	0 Child’s mother 1 Child’s father 2 Non-parental partner of your child’s mother/ father 3 Child’s grandparent 4 Child’s relative under age 18 (including a sibling younger than 18) 5 Other adult relative (including a sibling 18 or older) 6 Friend or neighbor 7 Unrelated adult (including a professional at a child care center) 8 Other 88 Refused 66 Not applicable – I do not have another person who cares for my child (If not applicable, skip to question #10).
	If other, specify:______________________________
9n. Does this person help care for your child in the following locations?
In the child’s home	1 Yes 0 No 88 Refused
In someone else’s home	1 Yes 0 No 88 Refused
In a childcare center/nursey	1 Yes 0 No 88 Refused
Other	1 Yes 0 No 88 Refused
	If other, specify:______________________________
9o. How many days per week does this person help care for your child?	_______ days/week 88 Refused
9p. On days when this person helps care for your child, how many hours per day?	_______ hours/day 88 Refused
9q. On average, how many additional children does this person care for at the same time as your child?	________ children 88 Refused
9r. On average, how many additional people also provide care for your child alongside this person?	________ people 88 Refused

10. How satisfied are you with the amount of help you receive in caring for your child?

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 crying patterns your child may be having.

11. How many hours per day would you say your child 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

12. In general, how easy is it to calm your child when he or she is crying or fussy?
    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 your child’s healthcare.

13. What type of health insurance does your child have?

₁ Contributory     ₂ Subsidized     ₃ Not insured   ₄ Specialized    ₅ Exception 

₆ Indeterminate / independent        ₇₇ Don’t know ₈₈ Refused

14. What is the name of your child’s health insurance provider?

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

₆₆ Not applicable

Since your child’s birth, have you sought medical care for your child?	1 Yes 0 No 77 Don’t know 88 Refused If Yes: Number of times:____________ Clinic name (1):_______________________________ Clinic name (2):_______________________________ Clinic name (3):_______________________________ Clinic name (4):_______________________________ Clinic name (5):_______________________________
Without including tests done as part of the study, since your child’s last study visit, did your child have any of the following tests? Say “yes” or “no” to each one of the tests that I mention. Did your child have a…
Cranial ultrasound	1 Yes 0 No 77 Don’t know 88 Refused
	If Yes: Number of visits:_______ Clinic name (1):___________________________________ Clinic name (2):___________________________________
MRI of the head	1 Yes 0 No 77 Don’t know 88 Refused
	If Yes: Number of visits:_______ Clinic name (1):___________________________________ Clinic name (2):___________________________________
CAT scan of the head	1 Yes 0 No 77 Don’t know 88 Refused
	If Yes: Number of visits:_______ Clinic name (1):___________________________________ Clinic name (2):___________________________________
Hearing test	1 Yes 0 No 77 Don’t know 88 Refused
	If Yes: Number of visits:_______ Clinic name (1):___________________________________ Clinic name (2):___________________________________
Vision test	1 Yes 0 No 77 Don’t know 88 Refused
	If Yes: Number of visits:_______ Clinic name (1):___________________________________ Clinic name (2):___________________________________
Developmental assessment	1 Yes 0 No 77 Don’t know 88 Refused
	If Yes: Number of visits:_______ Clinic name (1):___________________________________ Clinic name (2):___________________________________
Did your child have any other tests I didn’t mention?	1 Yes 0 No 77 Don’t know 88 Refused If Yes:
	Test (1): _______________________________________ Clinic name (1):__________________________________
	Test (2): _______________________________________ Clinic name (2):__________________________________
	Test (3): _______________________________________ Clinic name (3):__________________________________
	Test (4): _______________________________________ Clinic name (4):__________________________________
	Test (5): _____________________________________ __ Clinic name (5):__________________________________
Since your child’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 specialist did your child see? Say “yes” or “no” to each one I mention. Did your child 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
ENT	1 Yes (Clinic name:_______________________________) 0 No 77 Don’t know 88 Refused
Geneticist	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 your child see any other type of medical specialist I didn’t mention?	1 Yes (Provider type:_______________________________ Clinic name:________________________________) 0 No 77 Don’t know 88 Refused
Since your child’s last study visit, has your child spent one night or more in the hospital?	1 Yes 0 No 77 Don’t know 88 Refused If Yes: Number of times:____________ Hospital name (1):_______________________________ Hospital name (2):_______________________________ Hospital name (3):_______________________________ Hospital name (4):_______________________________ Hospital name (5):_______________________________
Now I will give you a list of conditions. Please say “yes” or “no” if, since your child’s last study visit, a healthcare provider told you that your child might have this illness. Did they say that your child 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 your child had something else I didn’t mention?	1 Yes 0 No 77 Don’t know 88 Refused If Yes, specify: _____________________________________

20. Since your last study visit, have you or your child 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 your relationships, family and friends.

21. What is your marital status?

₁ Married

₂ Free Union

₃ Single, divorced, or widowed

₄ Other, specify: ______________

₇₇ Don’t know

₈₈ Refused

22. We are interested in how you feel about the following statements. I will read each statement to you from your point of view. 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.

23. 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

24. Since the birth of the child enrolled in ZEN, 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

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

25. Since your baby’s birth, has anyone done any of the following things in the child’s house? 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.

Note any questions from parents below:_______________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Appendix F8, version 08FEB2018

CDC estimates the average public reporting burden for this collection of information as 15 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).