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Form 96 _Powerpoint_

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					 OBSTETRICS & PERIO THERAPY STUDY II                                                                             attach PID label here


 PARENT/CAREGIVER DEMOGRAPHICS                                                                     Patient ID:                       -    -
                    DCC USE                                                                           Clinical Unit:
  Date
  Received:                                                                                             Form Date:              -         -
                                                                                                                        Month       Day       Year
  Form
  Seq. No.:                                                                                    Coordinator Code:
                                                                                                                 Visit: 1           2

  1. What is the race of the primary caregiver?
       Ask the subject “Which of these groups describes your ancestry?” Check ALL that apply.
       (Use definitions only if subject seems unsure about a group.)
       1      Caucasian / White
              A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
       1      Black or African American
              A person having origins in any of the black racial groups of Africa.
       1      Asian
              A person having origins in any of the original peoples of the Far East, Southeast Asia including the Philippine Islands, or the Indian
              subcontinent.
       1      American Indian or Alaska Native
              A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliations or
              community attachment.
       1      Native Hawaiian or Other Pacific Islander
              A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

       1      Don't know/Refused


  2. Is the primary caregiver Hispanic?                    1     Yes                 2   No


  3. What is the primary caregiver's primary language?
     1 English                    2 Spanish                              3     Other, describe: ____________________________


  4. What is the primary caregiver's highest education level completed?
     1 Less than 7th grade                           5 Partial college (at least 1 year or completed specialized training)
     2 7   th, 8th, 9th grade                        6 College or university graduate
     3 10th or 11th grade                            7 Graduate degree
     4 high school graduate or GED


   5. What is the primary caregiver's occupation? __________________________________________________________


   6. Is the primary caregiver the child's biological mother?
       1      Yes          SKIP TO Q. 12
       2      No


OPT Form 96         V1   (1-3)    MAR 06
 OBSTETRICS & PERIO THERAPY STUDY II                                                             Patient ID:                     -     -


  7. What is the race of the biological mother?
       1    Caucasian / White
            A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
       1    Black or African American
            A person having origins in any of the black racial groups of Africa.
       1    Asian
            A person having origins in any of the original peoples of the Far East, Southeast Asia including the Philippine Islands, or the Indian
            subcontinent.
       1    American Indian or Alaska Native
            A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliations or
            community attachment.
       1    Native Hawaiian or Other Pacific Islander
            A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

       1    Don't know


  8. Is the biological mother Hispanic?                  1     Yes                 2   No               3    Don't know


  9. What is the biological mother's primary language?
     1 English                     2 Spanish                           3     Other, describe: ____________________________


 10. What is the biological mother's highest education level completed?
     1 Less than 7th grade                           5 Partial college (at least 1 year or completed specialized training)
     2 7   th, 8th, 9th grade                        6 College or university graduate
     3 10th or 11th grade                            7 Graduate degree
     4 high school graduate or GED                   8 Don't know


 11. What is the biological mother's occupation? __________________________________________________________


 12. Is the primary caregiver the child's biological father?
      1    Yes         SKIP TO Q. 18
      2    No




OPT Form 96      V1    (2-3)    MAR 06
 OBSTETRICS & PERIO THERAPY STUDY II                                                             Patient ID:                     -     -


 13. What is the race of the biological father?
       1    Caucasian / White
            A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
       1    Black or African American
            A person having origins in any of the black racial groups of Africa.
       1    Asian
            A person having origins in any of the original peoples of the Far East, Southeast Asia including the Philippine Islands, or the Indian
            subcontinent.
       1    American Indian or Alaska Native
            A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliations or
            community attachment.
       1    Native Hawaiian or Other Pacific Islander
            A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

       1    Don't know


 14. Is the biological father Hispanic?                  1     Yes                 2   No               3    Don't know


 15. What is the biological father's primary language?
     1 English                      2 Spanish                          3     Other, describe: ____________________________


 16. What is the biological father's highest education level completed?
     1 Less than 7th grade                            5 Partial college (at least 1 year or completed specialized training)
     2 7   th, 8th, 9th grade                         6 College or university graduate
     3 10th or 11th grade                             7 Graduate degree
     4 high school graduate or GED                    8 Don't know


 17. What is the biological father's occupation? __________________________________________________________


 18. Are there other adults living in the same household with the child?
     (other than the primary caregiver, biological mother and biological father)

     1     Yes        18a. Please list relationship to child and occupation
     2     No                             relationship                                       occupation
                            1. __________________________                  ____________________________________________
                            2. __________________________                  ____________________________________________
                            3. __________________________                  ____________________________________________
                            4. __________________________                  ____________________________________________
                            5. __________________________                  ____________________________________________



OPT Form 96      V1    (3-3)    MAR 06

				
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