Multi-site Study Child Questionnaire – Short Form

Attachment 15a.

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/201x xx/xx/20xxExDaxx/xx/20xx

Exp. Date xx/xx/20xx

Multi-site Study Child Questionnaire – Short Form

ATSDR 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 (0923-xxxx).

(best completed by the child’s birth mother who is also an adult participant)

Adult Study ID No. |_________________| (alias)

Parent Study ID No. |_________________|

Child Study ID No. |_________________|

Section A: Demographic Information

A1. What is your relationship to your child?

___Birth mother

___Birth father

___Adoptive mother

___Adoptive father

___Legal guardian

___Other relationship: specify ____________________________

___Refused to answer

A2. What is your child’s sex?

___Male

___Female

___Refused to answer

A3. What is your child’s age, in years?

_________ years

___Refused to answer

A4. Do you consider your child to be Hispanic or Latino?

___Yes

___No

___Refused to answer

A5. What race do you consider your child to be? Mark all that apply.

___American Indian or Alaska Native

___Asian

___Black or African American

___Native Hawaiian or Other Pacific Islander

___White

___Refused to answer

A6. What is the highest grade level of education your child has completed?

___grade

A.7 What is the highest level of education you completed?

___Less than high school

___Some high school

___High school graduate or equivalent (GED)

___Some university/college

___Technical or trade school

___University/college graduate

___Graduate school or higher

A8. What is the child’s household income (from all sources)?

___Less than $25,000

___$25,000 to $69,000

___$70,000 to $149,000

___More than $150,000

___Don’t know

___Refused to answer

A9. During the last 12 months did the child have any kind of health insurance?

___Yes

___No

___Don’t know

___Refused

Section B: Residential History and Drinking Water Exposures

B1. On average, how many 8 oz. cups of tap water or beverages prepared with tap water does your child currently drink per day at home?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)

B2. Please fill out the table below for all residences that your child has lived.

Street Address, City, State	Your child’s average consumption of tap water per day (# cups) at this address	Move in (mm/yy)	Main source of tap water at this address (public water system or private well?)

B3. When [you were/the child’s birth mother was] pregnant with your child, on average how many 8 oz. cups of tap water or beverages prepared with tap water did [you/she] drink per day?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

B4. When [you were/the child’s birth mother was] breastfeeding your child, on average how many 8 oz. cups of tap water or beverages prepared with tap water did [you/she] drink per day?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

___Did not breastfeed my child

Section C: History of Potential Exposure Modifiers

This next set of questions is for the child’s birth mother about the child. If you are not her, we can follow up after this interview with a quick phone call to complete the questionnaire.

C1. Has your child ever had a blood transfusion?

___Yes → Please specify how many times your child had a blood transfusion__________

___No →go to Question C3

___Don’t know →go to Question C3

___Refused to answer →go to Question C3

C2. When did your child last have a blood transfusion?

________month/year

C3. Has your child ever donated blood?

___Yes → Please specify how many times your child has donated blood__________

___No →go to Section D.

___Don’t know →go to Section D.

___Refused to answer →go to Section D.

C4. When did your child last donate blood?

________ Month/Year

C5. On average, how often does your child donate blood in a year?

__________

Section D: Occupational History of the Child

This next set of questions is for the child’s birth mother about the child. If you are not her, we can follow up after this interview with a quick phone call to complete the questionnaire.

D1. Has your child been employed for at least one month at a job?

____Yes

____No → go to Section E.

Job information	Job 1	Job 2	Job 3
a. Where did your child work? (City, State)
b. Name of employer
c. Start date (month, year)
d. End date (month, year)
e. Job title/description
f. Did your child work with or around radiation or any chemicals at this job such as solvents, metals, asbestos, or pesticides?	Yes (Please specify) _______________ No ____ Don’t know___	Yes (Please specify) ________________ No___ D Don’t know____	Yes (Please specify) _______________ No____ Don’t know____

D2. On average how many 8 oz. cups of tap water or beverages prepared with tap water did [he/she] drink per day at work?

___ cups

___Didn’t drink tap water

___Don’t know

___Refused to answer

Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)

Section E: Child’s Daycare/School History

E1. Did your child attend day care?

____Yes

____No → go to Question E3

____Don’t know → go to Question E3

____Refused to answer → go to Question E3

E2. Please fill out the table below for the day care centers your child attended.

Day care (name)	Street Address, City, State	Start Date (mm/yy)	End Date (mm/yy)	Child’s average consumption of tap water per day (# cups)

Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)

E3. Please fill out the table below for the schools your child has attended. If your child was home schooled, please go to Section F

School (name)	Street Address, City, State	Start Date (mm/yy)	End Date (mm/yy)	Child’s average consumption of tap water per day (# cups)

Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)

Section F: Child’s Medical History

F1. Have you ever been told by a doctor or other health care provider that your child has or had any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.

Medical condition		If yes, what year was your child diagnosed?
Cancer?	Yes (Please specify) ________________ No Don’t know	_ _ _ _ year
Allergies?	Yes (Please specify)__________________ No Don’t know	_ _ _ _ year
Atopic dermatitis/eczema?	Yes (Please specify)__________________ No Don’t know	_ _ _ _ year
Asthma?	Yes No Don’t know	_ _ _ _ year
Chronic stuffy/runny nose (rhinitis/sinusitis)?	Yes No Don’t know	_ _ _ _ year
High cholesterol?	Yes No Don’t know	_ _ _ _ year
Thyroid disease?	Yes (Please specify)__________________ No Don’t know	_ _ _ _ year
Delayed puberty?	Yes (Please specify) _________________ No Don’t know	_ _ _ _ year
Obesity?	Yes No Don’t know	_ _ _ _ year
Lupus	Yes No Don’t know	_ _ _ _ year
Celiac disease	Yes No Don’t know	_ _ _ _ year
Crohn’s disease	Yes No Don’t know	_ _ _ _ year
Diabetes	Yes, Type 1 Yes, Type 2 Yes, Type unknown No Don’t know	_ _ _ _ year
Scleroderma	Yes No Don’t know	_ _ _ _ year
Attention deficit hyperactivity disorder (ADHD) or attention deficit disorder (ADD)?	Yes No → go to p Don’t know → go to p	_ _ _ _ year
Autism?	Yes No → go to q Don’t know → go to q	_ _ _ _ year
Other learning or behavioral problems?	Yes (Please specify) ________________ No → go to Question B2. Don’t know → go to Question B2.	_ _ _ _ year

F2.. What age was your child last vaccinated for:

Diphtheria, Tetanus, Pertussis (“DTaP”) age_____ Don’t know ___ never was vaccinated ____

“Tdap” booster Tetanus, Diptheria, Pertussis age_____ Don’t know ___ never was vaccinated ____

Measles, Mumps, Rubella (“MMR”) age_____ Don’t know ___ never was vaccinated ____

Tetanus shot (for a puncture wound or cut) age_____ Don’t know ___ never was vaccinated ____

FOR GIRLS ONLY

F3. Has your daughter ever used an oral contraceptive (“birth control pill”)?

___Yes

___No → go to Question E5

___Don’t know → go to Question E5

___Refused to answer → go to Question E5

F4. When did your daughter last use an oral contraceptive (“birth control pill”)?

________Month/Year

F5. At what age did your daughter begin menstruation (have her first period)?

___Age

___Has not yet begun to menstruate → go to Section G

___Don’t know

F6. Does your daughter’s period occur regularly (every month)?

___Yes

___No, it is irregular

___No, she does not have a period → go to Question E10

___Don’t know → go to Question E10

F7. How many days has been your daughter’s cycle on average during the last year?

___>26 days

___27-29 days

___30-32

___>32 days

___Don’t know

F8. Can you characterize your daughter’s usual period flow during the last year?

___Light

___Medium

___Heavy

___Don’t know

F9. When was your daughter’s last period before this study blood draw?

Date:______________

___Don’t know

F10. Has your daughter ever been pregnant?

___Yes

___No → go to Section G

___Don’t Know → go to Section G

___Refused to answer → go to Section G

F11. How many times has your daughter been pregnant?

________

	Pregnancy #1	Pregnancy #2	Pregnancy #3
a. What month and year did this pregnancy start?	_ _ / _ _ _ _	_ _ / _ _ _ _	_ _ / _ _ _ _
b. What month and year did this pregnancy end?	_ _ / _ _ _ _	_ _ / _ _ _ _	_ _ / _ _ _ _
c. Did the pregnancy result in a live birth?	Yes No (go to g) Don’t Know	Yes No (go to g) Don’t Know	Yes No (go to g) Don’t Know
d. Did your daughter breastfeed the child?	Yes No (go to g) Don’t Know	Yes No (go to g) Don’t Know	Yes No (go to g) Don’t Know
e. How long did your daughter breastfeed the child?	_ _ months	_ _ months	_ _ months
f. When did your daughter stop breastfeeding the child?	__month ____ year	__month ____ year	__month ____ year
g. Did a doctor or nurse say that your daughter had pre-eclampsia during her pregnancy?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
h. Did a doctor or nurse say that your daughter had pregnancy-induced hypertension?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
i. Did a doctor or nurse say that your daughter had gestational diabetes?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know

Section G: Family Medical History

G1. Have any of your child’s blood relatives - grandparents, parents, or siblings - ever been told by a health professional that they have or had any of the following conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.

Medical condition		If yes, ask: Which relative had this condition?
Obesity	Yes No Don’t know	Grandparent Parent Sibling
Attention deficit hyperactivity disorder (ADHD or attention deficit disorder (ADD)	Yes No Don’t know	Grandparent Parent Sibling
Autism	Yes No Don’t know	Grandparent Parent Sibling
Other learning or behavioral problems	Yes No Don’t know	Grandparent Parent Sibling

CONCLUSION: That completes this survey. I would like to sincerely thank you for your time.

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