Document ID: EPA-HQ-ORD-2005-0010-0038
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2005-09-28T04:00Z

Event
Form
(
Instrument
#
30)

NCS
Herald
Cohort
Study
Instrument
#
30
Event
Form
Eligibility:
All
women
and
study
child
Mode
of
administration:
Self­
Administered
8/
4/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
5
minutes
per
response,
including
the
time
for
reviewing
instructions,
searching
existing
data
sources,
gathering
and
maintaining
the
data
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:
Dr.
Pauline
Mendola,
US
EPA,
MD­
58A,
Research
Triangle
Park,
NC
27711.
E­
mail:
mendola.
pauline@
epa.
gov.
Event
Form
(
Instrument
#
30)

North
Carolina
Herald
Cohort
Event
Form
For
Mothers
and
their
Child
I
D#
___________________________

Please
use
this
form
to
document
any
illnesses,
non­
routine
visits
to
the
doctor,
emergency
room
visits,
hospital
admissions
or
illnesses
for
yourself
or
your
child
in
the
study.

When
complete,
please
return
this
form
in
the
provided
postage
paid
envelopes.
If
you
have
any
questions
on
what
to
include,
please
contact
the
study
coordinator,
XXXXXX
at
1­
800­
334­
8531
ext.
XXXX.

Thank
you
1)
Who
experienced
the
event?
1
Mother
2
Child
2)
Event
Type:
(
PLEASE
CIRCLE
ALL
EVENTS
THAT
APPLY)

a)
Non­
Routine
doctor
visit.
Date
of
Visit
__/__/__
(
PLEASE
DESCRIBE
REASON
FOR
VISIT)_____________________________________________

b)
Emergency
Room
Visit
Date
of
Visit
__/__/__
(
PLEASE
DESCRIBE
REASON
FOR
EMERGENCY
ROOM
VISIT)

__________________________________________________________________

c)
Hospital
Admission
Date
of
Admission
__/__/__
Date
of
Discharge
__/__/__

(
PLEASE
DESCRIBE
REASON
FOR
HOSPITAL
ADMISSION)

___________________________________________________________________

d)
Significant
Illness
that
did
not
result
in
medical
attention:
Date
of
illness
__/__/__

(
PLEASE
DESCRIBE
THE
ILLNESS)
_______________________________________

e)
Other
medical
event
Date
of
event:
__/__/__
(
PLEASE
DESCRIBE
THE
MEDICAL
EVENT)_____________________________________________________________