PARENT/CAREGIVER DEMOGRAPHICS

OPT Form 96 V1 (1-3) MAR 06

Clinical Unit:

Form Date: - -Month Day Year

attach PID label here

Patient ID: - -

DCC USE

Received:

Date

Seq. No.:Form

Coordinator Code:

OBSTETRICS & PERIO THERAPY STUDY II

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

4. What is the primary caregiver's highest education level completed?1 Less than 7th grade2 7th, 8th, 9th grade3 10th or 11th grade4 high school graduate or GED

5 Partial college (at least 1 year or completed specialized training)6 College or university graduate7 Graduate degree

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

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 / WhiteA person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

1 American Indian or Alaska NativeA person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliations or community attachment.

1 AsianA person having origins in any of the original peoples of the Far East, Southeast Asia including the Philippine Islands, or the Indian subcontinent.

1 Black or African AmericanA person having origins in any of the black racial groups of Africa.

1 Native Hawaiian or Other Pacific IslanderA person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

1 Don't know/Refused

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

6. Is the primary caregiver the child's biological mother?

2 No

1 Yes SKIP TO Q. 12

21Visit:

OPT Form 96 V1 (2-3) MAR 06

Patient ID: - -OBSTETRICS & PERIO THERAPY STUDY II

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

7. What is the race of the biological mother?

1 Caucasian / WhiteA person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

1 American Indian or Alaska NativeA person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliations or community attachment.

1 AsianA person having origins in any of the original peoples of the Far East, Southeast Asia including the Philippine Islands, or the Indian subcontinent.

1 Black or African AmericanA person having origins in any of the black racial groups of Africa.

1 Native Hawaiian or Other Pacific IslanderA person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

1 Don't know

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

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

10. What is the biological mother's highest education level completed?1 Less than 7th grade2 7th, 8th, 9th grade3 10th or 11th grade4 high school graduate or GED

5 Partial college (at least 1 year or completed specialized training)6 College or university graduate7 Graduate degree8 Don't know

12. Is the primary caregiver the child's biological father?

2 No

1 Yes SKIP TO Q. 18

OPT Form 96 V1 (3-3) MAR 06

Patient ID: - -OBSTETRICS & PERIO THERAPY STUDY II

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

13. What is the race of the biological father?

1 Caucasian / WhiteA person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

1 American Indian or Alaska NativeA person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliations or community attachment.

1 AsianA person having origins in any of the original peoples of the Far East, Southeast Asia including the Philippine Islands, or the Indian subcontinent.

1 Black or African AmericanA person having origins in any of the black racial groups of Africa.

1 Native Hawaiian or Other Pacific IslanderA person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

1 Don't know

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

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

16. What is the biological father's highest education level completed?1 Less than 7th grade2 7th, 8th, 9th grade3 10th or 11th grade4 high school graduate or GED

5 Partial college (at least 1 year or completed specialized training)6 College or university graduate7 Graduate degree8 Don't know

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

2 No

1 Yes 18a. Please list relationship to child and occupation

relationship occupation

1. __________________________ ____________________________________________

2. __________________________ ____________________________________________

3. __________________________ ____________________________________________

4. __________________________ ____________________________________________

5. __________________________ ____________________________________________