Child questionnaire - long form

Attachment 15.

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 – Long Form

ATSDR estimates the average public reporting burden for this collection of information as 30 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 not an adult participant)

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

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

B1. Is your current address in the study area [enter SITEs/Communities of interest e.g. Hyannis, Ayer public water supply area]?

If not, please go to B3.

If yes, please provide the following information:

Street______________________________ Apt______

City _______________________ State __ __ Zip Code:________

B2 .When did you move to this address?

Month____ Year_______

B3. What is the source of tap water at your current address?

____ Public water system

____ Private well

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer

B4. Has this source changed while you’ve lived at your current address?

____ Yes

____ No → go to Question B7

____ Don’t know → go to Question B7

____ Refused to answer → go to Question B7

If yes: B5. What was the previous source?

____ Public water system

____ Private well

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer

B6. When did this change occur?

Month____ Year_______

B7. What proportion of the water you drink at home is tap water versus bottled water at your current address? Include water used for beverages like coffee and tea.

____ All tap, no bottled water

____ Mostly tap, a little bottled water

____ Similar amounts of tap and bottled

____ Mostly bottled, little to no tap

____ All bottled water

____ Don’t know

____ Refused to answer → go to Question B11

B8. Has this pattern changed over time, while you’ve been living at your current address?

____ Yes

____ No → go to Question B11

____ Don’t know → go to Question B11

____ Refused to answer → go to Question B11

B9. If yes: When your water consumption pattern used to be different than it is now, how would you describe it?

____ All tap, no bottled water

____ Mostly tap, a little bottled water

____ Similar amounts of tap and bottled

____ Mostly bottled, little to no tap

____ All bottled water

____ Don’t know

____ Refused to answer

B10. When did this change occur?

Month____ Year_______

B11. What proportion of the water your child drinks at home is tap water versus bottled water at your current address? Include water used for beverages like coffee and tea.

____ All tap, no bottled water

____ Mostly tap, a little bottled water

____ Similar amounts of tap and bottled

____ Mostly bottled, little to no tap

____ All bottled water

____ Don’t know

____ Refused to answer → go to Question B15

B12. Has this pattern changed over time, while your child has been living at your current address?

____ Yes

____ No → go to Question B15

____ Don’t know → go to Question B15

____ Refused to answer → go to Question B15

B13. If yes: When your child’s water consumption pattern used to be different than it is now, how would you describe it?

____ All tap, no bottled water

____ Mostly tap, a little bottled water

____ Similar amounts of tap and bottled

____ Mostly bottled, little to no tap

____ All bottled water

____ Don’t know

____ Refused to answer

B14. When did this change occur?

Month____ Year_______

B15. Do you currently filter the tap water that you and your child drink at home? [Skip this question if answered “All bottled water” above]

____ Yes

____ No → go to Question B19

____ Don’t know → go to Question B19

____ Refused to answer → go to Question B19

B16. If yes:

Where is the filter located?

____ Filter pitcher

____ Under the kitchen sink

____ In the refrigerator

____ Whole-house filtration

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer

B17. What type of filter?

____ Granular activated carbon (Brita, PUR, others…)

____ Solid block carbon

____ Reverse osmosis

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer

B18. Have you always used this type of filter while you’ve lived at your current address?

____ Yes

____ No

____ Don’t know

____ Refused to answer

If no: When did you start using this filter?

Month____ Year_______

B19. On average, how many 8 oz. cups of tap water or beverages prepared with tap water do you currently drink per day at home?

___ Cups

___ Don’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.)

B20. 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

___ Don’t drink tap water

___ Don’t know

___ Refused to answer

B21. What was your previous address in the designated study area [insert site/community served by PFAS contaminated water]?

Street ____________________________________ Apt _____

City___________________________ State __ __ Zip Code:_________

B22. When did you move into your previous home? Month____ Year_______

B23. What was the main source of tap water at that address?

____ Public water system

____ Private well

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer

B24. Did this source change while you lived at this address?

____ Yes

____ No → go to Question B27

____ Don’t know → go to Question B27

____ Refused to answer → go to Question B27

B25. If yes: What was the previous source of tap water at that address?

____ Public water system

____ Private well

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer

B26. When did it change?

Month____ Year_______

B27. What proportion of the water you drank while you lived at that address was tap water versus bottled water? Include water used for beverages like coffee and tea.

____ All tap, no bottled water

____ Mostly tap, a little bottled water

____ Similar amounts of tap and bottled

____ Mostly bottled, little to no tap

____ All bottled water

____ Don’t know

____ Refused to answer

B28. Did this pattern change over time while you lived at this address?

____ Yes

____ No → go to Question B26

____ Don’t know → go to Question B22

____ Refused to answer → go to Question B22

B29. If yes: When your water consumption pattern changed at this address, how would you describe it?

____ All tap, no bottled water

____ Mostly tap, a little bottled water

____ Similar amounts of tap and bottled

____ Mostly bottled, little to no tap

____ All bottled water [IF yes then Go to B6]

____ Don’t know

____ Refused to answer

B30. When did this change occur?

Month____ Year_______

B31. What proportion of the water your child drank while you lived at that address was tap water versus bottled water? Include water used for beverages like coffee and tea.

____ All tap, no bottled water

____ Mostly tap, a little bottled water

____ Similar amounts of tap and bottled

____ Mostly bottled, little to no tap

____ All bottled water

____ Don’t know

____ Refused to answer

B32. Did this pattern change over time while your child lived at this address?

____ Yes

____ No → go to Question B35

____ Don’t know → go to Question B35

____ Refused to answer → go to Question B35

B33. If yes: When your child’s water consumption pattern changed at this address, how would you describe it?

____ All tap, no bottled water

____ Mostly tap, a little bottled water

____ Similar amounts of tap and bottled

____ Mostly bottled, little to no tap

____ All bottled water [IF yes then Go to B6]

____ Don’t know

____ Refused to answer

B34. When did this change occur?

Month____ Year_______

B35. Did you filter the tap water you and your child drank while you lived at this address? [Skip this question if answered “All bottled water” above]

____ Yes

____ No → go to Question B40

____ Don’t know → go to Question B40

____ Refused to answer → go to Question B40

B36. If yes:

Where was the filter located?

____ Filter pitcher

____ Under the kitchen sink

____ In the refrigerator

____ Whole-house filtration

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer

B37. What type of filter was it?

____ Granular activated carbon

____ Solid block carbon

____ Reverse osmosis

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer

B38. Did you always use this type of filter while you lived at this address?

____ Yes → go to Question B40

____ No

____ Did not drink tap water → go to Question B40

____ Don’t know → go to Question B40

____ Refused to answer → go to Question B40

B39. If no: When did you start using this filter at this address?

Month____ Year_______

B40. On average, how many 8 oz. cups of tap water or beverages prepared with tap water did you drink per day when you lived at that address?

___ cups

___Don’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.)

B41. On average, how many 8 oz. cups of tap water or beverages prepared with tap water did your child drink per day when you lived at that address?

___ Cups

___Don’t drink tap water

___Don’t know

___Refused to answer

B42. Have you lived at any other address within the designated study area since January 2000?

___ Yes Go to B43

___ No → go to Question B44

___ Don’t know → go to Question B44

___ Refused to answer → go to Question B44

B43. Please fill out the table below for these other residences where you lived since January 2000.

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

B44. 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

B45. 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 about the child and the child’s birth mother. If you are not her, we can follow up after this interview with a quick phone call to complete the questionnaire.

C1. [Have you/Has the birth mother] ever had a blood transfusion?

___Yes → Please specify how many times you 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 [you/she] last have a blood transfusion?

________month/year

C3. Has your child ever had a blood transfusion?

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

___No →go to Question C5

___Don’t know →go to Question C5

___Refused to answer →go to Question C5

C4. When did your child last have a blood transfusion?

________month/year

C5. [Have you/Has the birth mother] ever donated blood?

___Yes → Please specify how many times you have donated blood___________

­­­___No →go to Question C8

___Don’t know →go to Question C8

___Refused to answer →go to Question C8

C6. When did [you/the birth mother] last donate blood?

________ Month/Year

C7. On average, how often [do you/does the birth mother] donate blood in a year?

__________

C8. Has your child ever donated blood?

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

___No →go to Question D1.

___Don’t know →go to Question D1.

___Refused to answer →go to Question D1.

C9. When did your child last donate blood?

________ Month/Year

C10. On average, how often does your child donate blood in a year?

__________ times

Section D: Occupational History

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

D1. What is [your/the child’s birth mother’s] primary occupation?

_______________________________________

D2. On average, how many 8 oz. cups of tap water or beverages prepared with tap water do you currently drink per day at work?

___ cups

___Don’t drink tap water

___Don’t know

___Refused to answer

D3. Please fill out the table below for each job that lasted one month or more starting from the present and working back to 2000.

Job information	Job 1	Job 2	Job 3	Job 4
a. Where did the child’s mother work (City, State)
b. Name of the employer
c. Start date (month, year)
d. End date (month, year)
e. Job title/description
f. Did the child’s mother work as a firefighter? If the child’s mother worked as a firefighter, did she come into contact with firefighting foam used for fires that involve flammable liquids (also known as Class B fires)?	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____
g. Was this job in any of the following industries?	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no
h. Did the child’s mother work with or around any chemicals at this job such as solvents, metals, asbestos, or pesticides?	Yes (Please specify the chemical) _______________ No ____ Don’t know___	Yes (Please specify the chemical) ________________ No___ D Don’t know___	Yes (Please specify the chemical) _______________ No____ Don’t know____	Yes (Please specify the chemical) _______________ No____ Don’t know____
i. Did the child’s mother work with radiation?	Yes___ No____	Yes___ No____	Yes___ No____	Yes___ No____

Job information	Job 5	Job 6	Job 7	Job 8
a. Where did the child’s mother work (City, State)
b. Name of the employer
c. Start date (month, year)
d. End date (month, year)
e. Job title/description
f. Did child’s mother work as a firefighter? If child’s mother worked as a firefighter, did she come into contact with firefighting foam used for fires that involve flammable liquids (also known as Class B fires)?	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____
g. Was this job in any of the following industries?	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no
h. Did child’s mother work with or around any chemicals at this job such as solvents, metals, asbestos, or pesticides?	Yes (Please specify the chemical) _______________ No ____ Don’t know___	Yes (Please specify the chemical) ________________ No___ D Don’t know___	Yes (Please specify the chemical) _______________ No____ Don’t know____	Yes (Please specify the chemical) _______________ No____ Don’t know____
i. Did child’s mother work with radiation?	Yes___ No____	Yes___ No____	Yes___ No____	Yes___ No____

Job information	Job 9	Job 10	Job 11	Job 12
a. Where did child’s mother work (City, State)
b. Name of the employer
c. Start date (month, year)
d. End date (month, year)
e. Job title/description
f. Did child’s mother work as a firefighter? If child’s mother worked as a firefighter, did she come into contact with firefighting foam used for fires that involve flammable liquids (also known as Class B fires)?	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____	Yes___ No____ go to question g. Yes____ No____ Don’t know____
g. Was this job in any of the following industries?	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no	Manufacturing of nonstick cookware ____yes ____no Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics _____yes ____no Manufacturing of water resistant clothing _____yes ____no
h. Did child’s mother work with or around any chemicals at this job such as solvents, metals, asbestos, or pesticides?	Yes (Please specify the chemical) _______________ No ____ Don’t know___	Yes (Please specify the chemical) ________________ No___ D Don’t know___	Yes (Please specify the chemical) _______________ No____ Don’t know____	Yes (Please specify the chemical) _______________ No____ Don’t know____
i. Did child’s mother work with radiation?	Yes___ No____	Yes___ No____	Yes___ No____	Yes___ No____

This next questions are about your child.

D4. 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 the 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____

D5. 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?
High Cholesterol?	Yes No Don’t know	_ _ _ _ year
Diabetes (not related to pregnancy)?	Yes, Type 1 Yes, Type 2 Yes, Type unknown No Don’t know	_ _ _ _ year
Thyroid disease?	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
Scleroderma?	Yes No Don’t know	_ _ _ _ year
Atopic dermatitis/eczema?	Yes (Please specify) __________________ No Don’t know	_ _ _ _ year
Allergies?	Yes (Please specify) __________________ No Don’t know	_ _ _ _ year
Chronic stuffy/runny nose (rhinitis/sinusitis)?	Yes No Don’t know	_ _ _ _ year
Asthma?	Yes No Don’t know	_ _ _ _ year
Delayed puberty?	Yes (Please specify) __________________ No Don’t know	_ _ _ _ year
Attention deficit hyperactivity disorder (ADHD or attention deficit disorder (ADD)?	Yes No → go to o Don’t know → go to o	_ _ _ _ year
Autism?	Yes No → go to p Don’t know → go to p	_ _ _ _ year
Other learning or behavioral problems?	Yes (Please specify) __________________ No Don’t know	_ _ _ _ year
Cancer?	Yes (Please specify) __________________ No Don’t know	_ _ _ _ year

F2. What age was your child last vaccinated for:

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

“Tdap” booster Tetanus, Diphtheria, 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 F5

___Don’t know → go to Question F5

___Refused to answer → go to Question F5

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 F10

___Don’t know → go to Question F10

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 F

___Don’t Know → go to Section F

___Refused to answer → go to Section F

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. Mother’s Pregnancy History

Starting with the pregnancy of your child in this study (Pregnancy 1) and including up to three of [your/the birth mother’s] previous pregnancies, please fill out the table below. Circle the appropriate response.

	Pregnancy 1	Pregnancy 2	Pregnancy 3	Pregnancy 4
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	Yes No (go to g) Don’t Know
d. Did [you/the child’s mother] breastfed this child/these children?	Yes No → go to Part j. Don’t know	Yes No → go to Part j. Don’t know	Yes No → go to Part j. Don’t know	Yes No → go to Part j. Don’t know
e. How long did [you/the child’s mother] breastfeed this child/these children?	_ _ months	_ _ months	_ _ months	_ _ months
f. When did [you/the child’s mother] stop breastfeeding this child/these children?	__month ____ year	__month ____ year	__month ____ year	__month ____ year
g. Did a doctor or nurse say that [you/the child’s mother] had pre-eclampsia during [your/her] pregnancy?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
	Pregnancy 1	Pregnancy 2	Pregnancy 3	Pregnancy 4
h. Did a doctor or nurse say that [you/the child’s mother] had pregnancy-induced hypertension?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know
i. Did a doctor or nurse say that [you/the child’s mother] had gestational diabetes?	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know	Yes No Don’t know

Section H: Family Medical History

H1. Do any of your child’s blood relatives – - currently have cancer or have they had cancer? We are only asking about family members who are blood relatives: grandparents, parents, and siblings.

___Yes

___No → go to Question H4

H2. In all, how many family members (not including yourself) have had (or now have) cancer?

___number

___Don’t know

H3. Now I’d like to get more information about each of your child’s relatives who had/has cancer. Fill out the table below. Circle appropriate response and ask the respondent to specify as directed. Complete the information for the first relative completely before asking about the next relative. Once information about all blood relatives with cancer has been collected, go to Question H4.

	First relative	Second relative	Third relative	Fourth relative
a. Was this relative a . . .	Grandparent Parent Sibling	Grandparent Parent Sibling	Grandparent Parent Sibling	Grandparent Parent Sibling
b. What type of cancer did this relative have
c. Is this relative	Living Deceased	Living Deceased	Living Deceased	Living Deceased
d. What year was your relative diagnosed with cancer?	_ _ _ _ Don’t know	_ _ _ _ Don’t know	_ _ _ _ Don’t know	_ _ _ _ Don’t know

H4. 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?
High Cholesterol?	Yes (Please specify)__________________ No Don’t know	Grandparent Parent Sibling
Diabetes (not related to pregnancy)?	Yes, Type 1 Yes, Type 2 Yes, type unknown No Don’t know	Grandparent Parent Sibling
Thyroid disease?	Yes (Please specify) ______________________ No Don’t know	Grandparent Parent Sibling
Obesity	Yes No Don’t know	Grandparent Parent Sibling
Lupus?	Yes (Please specify) ______________________ No Don’t know	Grandparent Parent Sibling
Celiac disease?	Yes No Don’t know	Grandparent Parent Sibling
Crohn’s disease?	Yes No Don’t know	Grandparent Parent Sibling
Scleroderma?	Yes No Don’t know	Grandparent Parent Sibling
Atopic dermatitis/eczema?	Yes No Don’t know	Grandparent Parent Sibling
Allergies?	Yes (Please specify) ______________________ No Don’t know	Grandparent Parent Sibling
Asthma?	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
Cancer?	Yes (Please specify) ______________________ 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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