UAB Questionnaire

STH (Worm) Study IRB-300002219 Kimberlin, David, PI

OMB Control No. 0920-****

                                                                                                                                                                     Exp. Date **/**/2019

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-****)

Subject ID Date: ____________

Child participating in the study to be tested for intestinal worms that can be acquired from the environment

First name:

Middle name:

Last name:

Date of birth: (MM-DD-YY)

Home address: House / apartment number:

Street name:

City / Town:

ZIP:

Mailing address (if different to home address):

Street name

City / Town

ZIP

Primary healthcare provider name:

Primary healthcare provider phone number:

Contact information of parent / guardian

First name:

Last name:

Home phone number:

Mobile phone number:

If testing results identify an intestinal worm what is the best method to contact you? (please circle)

Home phone mobile phone mailing address

What is your preference for any required treatment if test results are positive?

• Dr. Poole (the Pediatric Infectious Disease doctor from UAB) O

• Your own healthcare provider O

The following questions are all about the child participating in the study who will be tested for an intestinal worm infection:

Please circle the following that best describes your child’s:

1.Gender / sex: female male prefer not to answer

2. Ethnicity:

Hispanic / Latino

Not Hispanic/ Latino

Unknown

Prefer not to answer

3. Race (mark all that apply):

Black/African-American

White

Asian

American Indian/Alaska Native

Native Hawaiian/Pacific Islander

Unknown

Prefer not to answer

4. How long has your child lived in the current home? (years)______________________________

5. Where else has your child lived in the past 5 years? (Country, state, county, city/town)

______________________________________________________________________________________________________________________________________________________

6. Has your child traveled outside the U.S. in the past 5 years? (please circle)Yes No

If yes, which country / countries?________________________________________________

And when (year / Month)?______________________________________________________

7. Does your child come into contact with the following animals on a weekly basis? (circle all that apply)

Dogs Cats Pigs None Other _____________

8. Does your child play / work outside where their bare hands or bare feet are in contact with the soil?

Never Sometimes (less than once a month) often (at least monthly) not sure

9. How many hours on average does your child spend on screen time a day? (screen time includes watching T.V., playing video games or spending time on a computer, tablet, smartphone or other electronic devices)

Less than 2 hours 2 – 4 hours more than 4 hours

10. Do you think your child’s screen time prevents them from playing outside? Yes no

11. Does your child ever eat produce from a home garden? Yes no

12. Has your child ever been treated for an intestinal parasite? Yes no don’t know

If yes do you know which one? (circle all that apply)

hookworm roundworm whipworm pinworm don’t know Other _____________

13. What type of sanitation does your residence have?

Sewer Connection Septic Tank Cess Pit Straight Pipe

Don’t know Other _____________

14. Haw raw sewage contaminated any part of your property in the past year? Yes No

If yes, where? Yard/Dirt Inside the house Other __________

15. Do you pay a water bill? Yes No I don’t know

Form Completed By: Date:

Version date: February 28, 2019