23.5 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Child Teeth Instrument, Phase 2g

OMB Specification

Child Teeth Instrument

Event Category:	Time-Based
Event:	60M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
Domain:	Biospecimen
Document Category:	Sample Collection
Method:	Data Collector Administered
Mode (for this instrument*):	In-Person, CAI
OMB Approved Modes:	In-Person, CAI
Estimated Administration Time:	3 minutes
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
Version:	1.0
MDES Release:	4.0

​*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

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Child Teeth Instrument

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

BIOSPECIMEN CHILD TEETH COLLECTION 3

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Child Teeth Instrument

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

BIOSPECIMEN CHILD TEETH COLLECTION

(TIME_STAMP_BCT_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) FOR CHILD AND RESPONDENT ID (R_P_ID) FOR ADULT CAREGIVER

• PRELOAD CHILD'S FIRST NAME (C_FNAME) FROM THE PARTICIPANT VERIFICATION AND TRACING QUESTIONNAIRE.

• IF C_FNAME ≠ -1 OR -2, DISPLAY C_FNAME AS APPROPRIATE THROUGHOUT THE INSTRUMENT.

• IF C_FNAME = -1 OR -2, DISPLAY "the child" AS APPROPRIATE THROUGHOUT THE INSTRUMENT.

BCT01000/(TEETH_COLLECT_INTRO). We would like to collect {C_FNAME/the child}’s teeth.  To do this we will provide you with materials to mail us any baby teeth {C_FNAME/the child} loses after today.

DATA COLLECTOR INSTRUCTIONS

• IF THE ADULT CAREGIVER REFUSES THIS COLLECTION, SELECT REFUSED.

• OTHERWISE, SELECT CONTINUE AND REVIEW THE COLLECTION MATERIALS, COLLECTION INSTRUCTIONS, AND DATA COLLECTION FORM WITH THE ADULT CAREGIVER.

Label	Code	Go To
CONTINUE	1	DISTRIBUTE_METHOD
REFUSED	-1

BCT02000/(REFUSE_REASON). I am sorry that you have chosen not to participate in this collection.  Can you tell me why?

DATA COLLECTOR INSTRUCTIONS

• ENTER REASON FOR REFUSAL. 

Label	Code	Go To
TOO COMPLICATED	1	BCT04000
PHYSICAL LIMITATION	2	BCT04000
PARTICIPANT ILL/EMERGENCY	3	BCT04000
LANGUAGE ISSUE	4	BCT04000
NO TIME	5	BCT04000
UNCOMFORTABLE WITH COLLECTION PROCEDURES	6	BCT04000
OTHER	-5
REFUSED	-1	BCT04000
DON'T KNOW	-2	BCT04000

SOURCE

National Children’s Study, Legacy Phase (6M Child)

BCT03000/(REFUSE_REASON_OTH). SPECIFY: ____________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study, Legacy Phase (6M Child)

BCT04000. That’s fine.  Thank you for your time.  

PROGRAMMER INSTRUCTIONS

• GO TO COLLECTION_COMMENT.

BCT05000/(DISTRIBUTE_METHOD). HOW WAS THE KIT DISTRIBUTED TO THE ADULT CAREGIVER?

Label	Code	Go To
IN PERSON	1
BY MAIL	2
DID NOT DISTRIBUTE	-7	N_DISTRIB_REAS

BCT06000/(SPECIMEN_ID). RECORD THE SPECIMEN ID

 

 

|__|__|__|__|__|__|__|__|__|- |__|__|__|__| 

DATA COLLECTOR INSTRUCTIONS

• IF THE ADULT CAREGIVER AGREES TO COLLECT TEETH, RECORD THE SPECIMEN ID OF THE KIT PROVIDED TO HIM/HER.

PROGRAMMER INSTRUCTIONS

• CANNOT BE NULL.

• HARD EDIT: INCLUDE HARD EDIT IF FORMAT IS NOT TWO ALPHA, SEVEN NUMERIC CHARACTERS DASH TWO ALPHA, TWO NUMERIC CHARACTERS (AA # # # # # # #-AA##). 

BCT07000. Thank you for agreeing to send us your child’s baby teeth. 

PROGRAMMER INSTRUCTIONS

• GO TO COLLECTION_COMMENT.

BCT08000/(N_DISTRIB_REAS). WHY COULDN’T YOU GIVE THE KIT TO THE ADULT CAREGIVER?

Label	Code	Go To
ADULT CAREGIVER REFUSED	1	COLLECTION_COMMENT
NO TIME TO DISTRIBUTE KIT	2	COLLECTION_COMMENT
KIT UNAVAILABLE	3	COLLECTION_COMMENT
OTHER	-5

BCT09000/(N_DISTRIB_REAS_OTH). SPECIFY: _____________________________

BCT10000/(COLLECTION_COMMENT). RECORD ANY COMMENTS ABOUT THE CHILD TEETH COLLECTION KIT DISTRIBUTION PROCEDURE.

DATA COLLECTOR INSTRUCTIONS

• DOCUMENT ANY PROBLEMS OR CONCERNS ABOUT THE CHILD TEETH COLLECTION KIT DISTRIBUTION PROCEDURE.

Label	Code	Go To
NO COMMENTS	1	TIME_STAMP_BCT_ET
COMMENT	2

BCT11000/(COLLECTION_COMMENT_OTH). SPECIFY:  ________________________

(TIME_STAMP_BCT_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 3 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*).  Do not return the completed form to this address.