Project Title: Enhanced Surveillance to Identify Missed Opportunities for Prevention of Tuberculosis in the Foreign-Born
Project Dates: 2005 - 2007
Method: Face-to-face interview
Topic: Pediatric tuberculosis
Target Audience: Reported verifiable cases of tuberculosis
Principal Investigator(s): Amy L. Davidow, PhD (); Randall Reves, MD2 (); Dolly Katz, PhD3 ()
1. University of Medicine and Dentistry, New Jersey, Newark, New Jersey; 2. Denver Public Health and Hospitals Authority, Denver, Colorado; 3. Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
Tuberculosis Epidemiologic Studies Consortium (TBESC)
Preventing Tuberculosis in the Foreign Born
Data Collection Forms
for Pediatric Participants
Project Title: Enhanced Surveillance to Identify Missed Opportunities for Prevention of Tuberculosis in the Foreign-Born
Project Dates: 2005 - 2007
Method: Face-to-face interview
Topic: Pediatric tuberculosis
Target Audience: Reported verifiable cases of tuberculosis
Principal Investigator(s): Amy L. Davidow, PhD (); Randall Reves, MD2 (); Dolly Katz, PhD3 ()
1. University of Medicine and Dentistry, New Jersey, Newark, New Jersey; 2. Denver Public Health and Hospitals Authority, Denver, Colorado; 3. Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
Participant # ______
Preventing Tuberculosis in the Foreign-Born
Pediatric Participant Interview Face Sheet
Last Name
______
First Middle Name
Participant’s Name:
Last Name
______
First Middle Name
Participant’s Address:
Zip Code/Postal Code: ______
Participant’s
State Case Number |__|__|__|__|__|__|__|__|__|
Participant’s Phone Number (s):
(|__|__|__|) |__|__|__| - |__|__|__|__|
(|__|__|__|) |__|__|__| - |__|__|__|__|
No Phone/Phone Number Not Available
Participant’s Alien Registration Number:
(from Q G13)
|__|__|__| |__|__|__| |__|__|__|
Alien Registration Number Not Available / Participant’s Immigration Medical Services Number:
(from Q G13)
|__|__|__|__|__|__|__|__|__|__|__|__|
Immigration Medical Services Number
Not Available
Name Used at Entry to U.S./Canada (from Q G6a)
(if different from current name)
Has a source case been identified for this child?
1Yes
2No (Go to General Information section)
Has the source case agreed to participate?
1 Yes (Record name and Participant # of source case)
2 No (Do NOT record name or Participant # of source case)
Name of Source Case:
Last Name
______
First Name Middle Name
Source Case Participant Number:
|__|__|__|__|
Project Title: Enhanced Surveillance to Identify Missed Opportunities for Prevention of Tuberculosis in the Foreign-Born
Project Dates: 2005 - 2007
Method: Face-to-face interview
Topic: Pediatric tuberculosis
Target Audience: Reported verifiable cases of tuberculosis
Principal Investigator(s): Amy L. Davidow, PhD (); Randall Reves, MD2 (); Dolly Katz, PhD3 ()
1. University of Medicine and Dentistry, New Jersey, Newark, New Jersey; 2. Denver Public Health and Hospitals Authority, Denver, Colorado; 3. Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
Participant # ______
Preventing Tuberculosis in the Foreign-Born
Pediatric Participant Interview Form
General Information
Participant’s Zip Code/Postal Code: [To be taken from the participant’s face sheet]: ______
1 Homeless
Date of Interview: __ __/ __ __ / ______
m m d d y y y y
Time Interview Started: __ __ : __ __ AM PM
hours minutes
Time Interview Completed: __ __ : __ __ AM PM
hours minutes
Interviewer Number: ______Interviewer Initial: ______
TBESC Consortium Site:______
Date case was reported to Jurisdiction: __ __/ ______
m m y y y y
Language of Interview:
1 English2 Spanish
3 French
4 Russian
5 Tagalog / 6 Chinese (Mandarin)
7 Chinese (Cantonese)
8 Vietnamese
9 Hindi
10 Korean / 11 Haitian Creole
12 Urdu
13 Arabic
14 Ilocano (Iloko)
97 Other (Specify)
How well does the informant speak English? [Copy response from Participant Tracking Form]
1 Very Well 2 Well 3 Not Well 4 Not at all
Interview conducted with:
1 Bilingual Interviewer
2 Telephone Interpreter
3 In-person Interpreter from a Professional Agency
4 In-person Interpreter from a Community Group
5 In-person Interpreter from the Health Department
6 Not applicable; Interview conducted in English
97 Other (Specify) ______
Foreign Language (translated) Questionnaire Used:
1 Yes
2 No
98 Don’t know
Location of Interview:
1 Health Dept Clinic2 Hospital (Inpatient)
3 Hospital (Outpatient)
4 Private Office / 5 Home
6 Work Place
97 Other (Specify)
Section A: Demographic Information
I am going to ask you questions about you and your child. Your answers will help us make treatment work better for people with tuberculosis.
These questions will take about an hour to answer. If you don’t understand a question, please tell me. If you don’t know the answer to a question, tell me and we will go on to the next one. If you don’t want to answer a question, tell me and we will skip it. Is it OK to begin now?
First, I would like to ask you some questions about your child.
A1. What country was your child born in?
98 Don’t know
99 Refused to answer
A2. What city or town was your child born in?
2 Not applicable/Was not born in a city or town
98 Don’t know
99 Refused to answer
A3. What province or state was your child born in?
98 Don’t know
99 Refused to answer
A4. What is your child’s date of birth?
__ __ / __ __ / ______
mm dd yyyy
98 Don’t know
99 Refused to answer
A5. Is your child Hispanic or Latino?
1 Yes
2 No
98 Don’t know
99 Refused to answer
A6. What is your child’s race? [Mark all the racial groups that the informant mentions.]
1 Black or African
2 White
3 Asian Indian
4 Chinese
5 Filipino
6 Japanese
7 Korean
8 Vietnamese
9 Other Asian (Specify) ______
10 Guamanian/Chamorro
11 Native Hawaiian
12 Samoan
13 Other Pacific Islander (Specify) ______
14 American Indian or Alaska Native
15 Canadian Aboriginal
97 Other (Specify) ______
98 Don’t know
99 Refused to answer
A7. What is your child’s sex?
1 Male
2 Female
98 Don’t know
99 Refused to answer
A8. Are you the child’s birth mother/birth father?
1 Yes, birth mother
2 Yes, birth father
3 No
98 Don’t know
99 Refused to answer
A8a. Is this child adopted?
1 Yes
2 No (Specify relationship to child) ______
98 Don’t know
99 Refused to answer
A8b. When did you become this child’s parent/guardian?
_ _ / _ _ _ _
m m y y y y
98 Don’t know
99 Refused to answer
Section B: Socioeconomic Status
B1. This question is about the person in your child’s family who has the most education. I am going to read you a list. Please tell me the highest level of schooling this person has completed.
1 Eighth grade or less
2 Some high school/secondary school
3 High school/secondary school graduate or equivalent diploma
4 Some college/university
5 College/university graduate
6 Postgraduate (master’s, doctoral degree, medical school, law school, etc.)
97 Other (Specify) ______
98 Don’t know
99 Refused to answer
B2. Now I am going to ask you some questions about your family’s income. Who provides most of your family’s income? Is that you or somebody else?
1 Me (Ask question B3 about the informant)
2 Provide equally (Ask question B3 about the informant)
3 Nobody in family is providing any income (Ask question B3 about the informant)
4 Somebody else (Ask question B3 about this person)
98 Don’t know (Ask question B3 about the informant)
99 Refused to answer (Ask question B3 about the informant)
B3. Were you/was this person working when you were told that your child had tuberculosis?
1 Yes
2 No
98 Don’t know
99 Refused to answer
B3a. What kind of work did you/this person do?
Occupation:
98 Don’t know
99 Refused to answer
B3a1. Did you/this person move from place to place with the seasons?
1 Yes
2 No
98 Don’t know
99 Refused to answer
B3b. What country was this job in?
1 In the US/Canada (Go to question B5)
2 In another country
98 Don’t know
99 Refused to answer
B4. Did you/this person have a job either here or in another country BEFORE you were told your child had tuberculosis?
1 Yes
2 No
98 Don’t know
99 Refused to answer
B4a. What was the last job you/this person had BEFORE you were told your child had tuberculosis?
Occupation:
98 Don’t know
99 Refused to answer
B4b. Did you/this person move from place to place with the seasons?
1 Yes
2 No
98 Don’t know
99 Refused to answer
B4c. What country was this job in?
1 In the U.S./Canada
2 In another country
98 Don’t know
99 Refused to answer
B5. Have you/has this person ever worked in another country besides the U.S./Canada?
1 Yes
2 No
98 Don’t know
99 Refused to answer
B5a. What was the last job you/this person had in another country?
98 Don’t know
99 Refused to answer
This next set of questions asks about the household where your child lives here in the U.S./Canada.
B6. How many people live in that household, including your child?
______people
2 Child is homeless (Go to question B8)
98 Don’t know
99 Refused to answer
B6a. How many of them are less than 18 years old, including your child?
______children <18 years old
98 Don’t know
99 Refused to answer
B7. How many rooms are in the house where your child lives, not counting bathrooms?
______rooms
98 Don’t know
99 Refused to answer
B8. This question is about family income. By income, I mean money from jobs, social security, retirement, public assistance, and any other source of money. In the 12 months before you were told your child had tuberculosis, would you say the total family income was less than $20,000 or $20,000 and above? [If the person was paid in a currency other than the US or Canadian dollar, please ask the informant to estimate family income in US/Canadian dollars.]
1 Less than $20,000
2 $20,000 and above
98 Don’t know
99 Refused to answer
BOX B1Give income level show card to the informant. Write in the space below the letter of the income group selected by the informant.
B9. Of all these income groups, can you tell me which one best represents your total family income in the 12 months before you were told your child had tuberculosis?
SHOW “INCOME”CARD / ______
98 Don’t know
99 Refused to answer
Section C: Circumstances of Tuberculosis Diagnosis
These next questions are about your child’s tuberculosis illness.
C1. When did a doctor or nurse first tell you or someone else in your family that your child had tuberculosis? I am talking about your child’s current tuberculosis illness.
Diagnosis date: __ __ / ______
mm y y y y
98 Don’t know
99 Refused to answer
C2. What city and state/province was your child living in at that time?
City:
98 Don’t know
99 Refused to answer
State/Province:
98 Don’t know
99 Refused to answer
C3. Which of the following best describes where your child lived at the time you were told he/she had tuberculosis?
1 A house or apartment
2 A hotel or rooming house
3 A long term care facility
4 A homeless shelter (Go to C4)
5 An orphanage
97 Another kind of place? (Specify)
98 Don’t know
99 Refused to answer
C3a. Was this:
1 Your family’s house or apartment?
2 A relative’s house or apartment?
3 A friend’s house or apartment?
97 Other? (Specify)
98 Don’t know
99 Refused to answer
C4. Where did they find out that your child had tuberculosis? Was it at a . . .
1 Health department? (Specify name) ______
2 Tuberculosis clinic? (Specify name)
3 Hospital? (Specify name)
4 Private doctor’s office?
97 Another place? (Specify)
98 Don’t know
99 Refused to answer
BOX C1If this interview is being conducted in English, skip questions C5, C5a and C5a.1 below and go to Section D: Event that Led to Diagnosis, page 12.
C5. What language did the doctor or nurse use when he/she told you that your child had tuberculosis?
[If the language this health care worker spoke was different from the language in which the interview is being conducted, go to C5a. Otherwise, go to Question D1, page 12.]98 Don’t know
99 Refused to answer
C5a. Did somebody translate the doctor or nurse’s words into your language?
1 Yes
2 No
98 Don’t know
99 Refused to answer
C5a.1 Who translated the doctor or nurse’s words into your language? Was it . . .
1 A family member or friend?
2 Somebody who worked at the doctor’s office?
3 Somebody on the telephone?
98 Don’t know
99 Refused to answer
Section D: Event That Led to Diagnosis
D1. What was the main reason your child went to the doctor or nurse who told you he/she had tuberculosis?
1 Referred by another doctor/health care worker (Go to D1.a)
2 Symptoms (Mark here if informant mentions any specific symptoms
or says “child didn’t feel well.”)
3 Non-TB medical condition child already known to have
(Specify)
4 Regular or well-baby checkup
5 Screening for employment, insurance, school
6 Screening for living situation (orphanage, homeless shelter, etc.)
7 Immigration screening for entry to US/Canada
8 Screening to change visa status
9 Screening related to pregnancy/childbirth
10 Screening for post-adoption check-up
11 Contact investigation
97 Other (Specify)
98 Don’t know
99 Refused to answer
D1.a. Why did you go to the doctor/health care worker who referred your child?