NJ Inhome Asthma Pilot Phone Follow Up

Participant’s assigned Unique ID*

Interview / Home Visit Date (MM/DD/YYYY)*

Interviewer’s / CHW’s Initials*

What is your zip code?*

What is your relationship to this child? (e.g. mother/father, grandparent, guardian, other)*

What is your child’s gender?*

How old is your child? __________ years*

Please enter a number from 0 to 18.

Is your child Hispanic or Latino?*

What is your child’s race? (Select all that apply)*

White
Black or African American
Alaska Native or American Indian
Asian
Native Hawaiian or other Pacific Islander
Other (please specify below):
Decline

Other*

What is the highest grade or level of school YOU have finished?*

I didn’t go to school
8th grade or less
Some high school but did not graduate
High School graduate or GED
Some college / vocational or technical school
Graduated from college, graduate school

What language(s) do you speak most at home? (Select all that apply)*

Other

Has your child’s doctor or other health professional provided you with a written plan (action plan) to help you decide how to change your child’s asthma medicine in response to changes in his/her asthma?*

Yes
No
I don’t know

If yes, do you have a copy of your child’s current written plan (action plan) that I can see?*

Yes
No

[CHW must visually confirm that the caregiver has a copy of the child’s current asthma action plan to check yes]

The last time your child’s asthma got worse, did you use a written plan (action plan) to decide what medicines to use?*

Yes
No
I don’t know

In the past 6 months, how many work or school days have you or another adult caregiver missed because of your child’s asthma? ____________ number of days*

In the past 6 months, how many days of childcare or school has your child missed because of their asthma? ____________ number of days*

Acceptable response: not applicable/child does not go to childcare or school

Has your child received a flu shot in the past 12 months?*

Yes
No
No - child has an egg allergy
I don’t know

What are the ages of other children that live in the home? Do any of the other children also have asthma?*

Age in Years	Asthma

Add a new row for each child by clicking the plus sign to the right of the row.

Including yourself, how many adults (age 18 or older) live in the home? ___________ number of adults*

Please enter a number less than or equal to 30.

How many of the adults (age 18 or older) living in the home also have asthma? ___________ number of adults with asthma*

Please enter a number less than or equal to 30.

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Step 1 of 3 - General information

Caregiver Home Environment Questions