Parent Child Enrollment Questionnaire - trkchg

Att B9_Parent_Child_Enrollment_Questionnaire_08FEB2018_track.docx

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

Parent Child Enrollment Questionnaire - trkchg

OMB: 0920-1190

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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:______________________________________)


  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


  1. Does your child live with you?


1 Yes 0 No 77 Don’t know 88 Refused


  1. 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.


  1. 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.


  1. 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


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

_______ hours/day 88 Refused


    1. 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.


  1. 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



  1. 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.


  1. 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


  1. 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.


  1. 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



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


Name: _________________________________________    77 Don’t know 88 Refused

66 Not applicable



  1. 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):_______________________________

  1. 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):__________________________________

  1. 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

  1. 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):_______________________________


  1. 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: _____________________________________


  1. 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.


  1. What is your marital status?

1 Married

2 Free Union

3 Single, divorced, or widowed

4 Other, specify: ______________

77 Don’t know

88 Refused


  1. 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.


  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. 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.


  1. 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:_______________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Page 1 of 14

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).

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