Multi-site Study Child Questionnaire - Short Form

Attachment 15a.

Multi-site Study Child Questionnaire – Short Form

Form Approved
OMB No. 0923-XXXX
Exp. Date xx/xx/201x
(best completed by the child’s birth mother who is also an adult participant)
xx/xx/20xxExDaxx/xx/2
0xx
xx/xx/20xx
ATSDR estimates the average public reporting burden for this collection of information as 15 minutes per response, including theExp.
timeDate
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).

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
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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

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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
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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
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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

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___

Job 2

D

Yes (Please specify)
________________
No___
Don’t know____

Job 3

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.

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Day care
(name)

Street Address, City, State

Start
End
Child’s average
Date
Date
consumption of tap
(mm/yy) (mm/yy) 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
Child’s average
Date
consumption of tap
(mm/yy) 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.)

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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

a.

High Cholesterol?

b.

Diabetes (not related to
pregnancy)?

c.

Thyroid disease?

d.

Obesity

e.

Lupus?

f.

Celiac disease?

g.

Crohn’s disease?

h.

Scleroderma?

i.

Atopic dermatitis/eczema?

j.

Allergies?

k.

Chronic stuffy/runny nose
(rhinitis/sinusitis)?

l.

Asthma?

m. Delayed puberty?

Yes (Please specify)
________________
No
Don’t know
Yes (Please
specify)__________________
No
Don’t know
Yes (Please
specify)__________________
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes (Please
specify)__________________
No
Don’t know
Yes (Please specify)
_________________
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes, Type 1
Yes, Type 2
Yes, Type unknown
No
Don’t know

If yes, what year was your child
diagnosed?
_ _ _ _ year

_ _ _ _ year

_ _ _ _ year

_ _ _ _ year

_ _ _ _ year

_ _ _ _ year

_ _ _ _ year

_ _ _ _ year

_ _ _ _ year

_ _ _ _ year

_ _ _ _ year

_ _ _ _ year

_ _ _ _ year

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If yes, what year was your child
diagnosed?

Medical condition

n.

Attention deficit hyperactivity
disorder (ADHD or attention deficit
disorder (ADD)?

o.

Autism?

p.

Other learning or behavioral
problems?

q.

Cancer?

Yes
No
Don’t know

_ _ _ _ year

Yes
No → go to p
Don’t know → go to p
Yes
No → go to q
Don’t know → go to q
Yes (Please specify)
________________
No → go to Question B2.
Don’t know → go to Question B2.

_ _ _ _ year

_ _ _ _ year

_ _ _ _ year

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

Diphtheria, Tetanus, Pertussis (“DTaP”)
age_____
“Tdap” booster Tetanus, Diptheria, Pertussis age_____
Measles, Mumps, Rubella (“MMR”)
age_____
Tetanus shot (for a puncture wound or cut) age_____

Don’t know ___
Don’t know ___
Don’t know ___
Don’t know ___

never was vaccinated ____
never was vaccinated ____
never was vaccinated ____
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

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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?
________

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?

Pregnancy #1
__/____
__/____
Yes

Pregnancy #2
__/____
__/____
Yes

Pregnancy #3
__/____
__/____
Yes

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d. Did your daughter breastfeed the child?

e. How long did your daughter breastfeed the child?
f. When did your daughter stop breastfeeding the
child?
g. Did a doctor or nurse say that your daughter had preeclampsia during her pregnancy?
h. Did a doctor or nurse say that your daughter had
pregnancy-induced hypertension?
i. Did a doctor or nurse say that your daughter had
gestational diabetes?

No (go to g)

No (go to g)

No (go to g)

Don’t Know

Don’t Know

Don’t Know

Yes

Yes

Yes

No (go to g)

No (go to g)

No (go to g)

Don’t Know
_ _ months

Don’t Know
_ _ months

Don’t Know
_ _ months

__month ____ year
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know

__month ____ year
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know

__month ____ year
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.

If yes, ask: Which relative
had this condition?

Medical condition

a.

Obesity

Yes
No
Don’t know

Grandparent
Parent
Sibling

b.

Attention deficit hyperactivity
disorder (ADHD or attention deficit
disorder (ADD)

Yes
No
Don’t know

Grandparent
Parent
Sibling

c.

Autism

Yes
No
Don’t know

Grandparent
Parent
Sibling

d.

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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