UMMC Anthropometric Data

Sex (please circle): Insurance:

Female – Male – prefer not to answer Private - Government - none - prefer not to answer

Ethnicity: Hispanic/Latino Not Hispanic/Latino Unknown Prefer not to answer

Race (mark all that apply):

White

Black/African American

Asian

American Indian/Alaska Native

Native Hawaiian/Pacific Islander

Unknown

Prefer not to answer

OMB Control No. 0920-****

                                                                                                                                                 Exp. Date **/**/2019

| HOBBS, Charlotte, PI

Parasite Surveillance Project | UMMC IRB #2016-0111

In what country was your child born?

First Name*: Middle Name (or initial):

Child / Participant Contact Information:

Parent/Guardian Contact Information:

/

/

Subject ID:

Date:

Month

Day

Year

First name:

Last name:

Home phone number:

Cell / Mobile phone number:

Last Name*: Birthdate:

Current Home Address: Home Zip Code:

Home Phone#: Cell / Mobile Phone#:

How long has child lived in current home?

The public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-****)

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Height: inches Weight: lbs

Lead g/dL Hemoglobin ug/dL

Date: (MM/DD/YYYY) Date: (MM/DD/YYYY)

Vision Screening: Y or N - OD: / - OS: / - Date: (MM/DD/YYYY)

Parasite Surveillance Project | UMMC IRB #2016-0111

| HOBBS, Charlotte, PI

/

/

Subject ID:

Month

Day

Year

Parasite Surveillance Project | UMMC IRB #2016-0111

| HOBBS, Charlotte, PI

Date:

Form Completed By: Date:

COMMENTS

Version February 2019 1

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Chiari Type I Malformation Radiology Review Form
Author	DOM PC;[email protected]
File Modified	0000-00-00
File Created	2021-01-15