Columbia University Medical Center Biobank Survey

Columbia University Medical Center Biobank Survey
Thank you for agreeing to participate in this survey. All your answers will be completely confidential. Before you begin, please review the
following:
•
•
•
•
If you
Do NOT write your name anywhere on the questionnaire
Use ink or ballpoint pen
If your child is the patient enrolling in the study, please answer the questions from his/her perspective.
Erase or cross out completely any answer you wish to change
have any questions, please call Elana Levinson at 212-342-3101.
Institutlon;ll Rc\ ie\\ Board (CUMCIRB)
Approval Date
~
tRB"
AAAE3306
Inrt!81s
.Y!R:---~~-~
Columbia LJniversilv Medical Cenler
FAMILY HISTORY
Have any of your relatives (listed below) ever had any of the following medical conditions? If yes, please indicate the aqe at FIRST diaqnosis. Please DO
NOT include adoptive, half, or step relatives.
Maternal
Paternal
Maternal Aunts
Paternal Aunts
Sisters
Brothers
Mother
Father
Grandparents
and Uncles
and Uncles
Grand~arents
-­
Maternal
Paternal Aunts
Paternal
Maternal Aunts
Grandmother
Grandmother
DYes
DYes
DYes (age__) DYes (age__) (age__)
(age__)
o Yes (how o Yes (how
many
many
o No
o No
o No
DO No
DYes
Yes (age__)
brothers? - ,
sisters? - ,
o
Don't
know
o
Don't
know
o
Don't
know
o Don't know
(age__)
Congenital o No
ages
ages
)
heart
o Don't know o No
Maternal
Paternal
Maternal Uncles
Paternal Uncles
disease
o No
o No
Grandfather
Grandfather
ODon't know
DYes
DYes
ODon't know o Don't know
DYes (age__) DYes (age__) (age__)
(age__)
o No
o No
o No
o No
o Don't know
o Don't know
o Don't know
o Don't know
Other
birth
defect
Autism
Yes (age__)
o No
o Don't know
DYes
(age__)
o No
ODon't know
DYes
(age__)
o No
o Don't know
DYes
(age__)
o No
ODon't know
o Yes (how
many
sisters? - '
ages
)
o No
ODon't know
o Yes (how
many
brothers? - '
ages
o
o
No
Don't know
o Yes (how
many
sisters? -,
ages
o Yes (how
many
brothers? -,
ages
o No
o No
o Don't
ODon't know
know
Maternal
Grandmother
DYes (age__)
o No
o Don't know
Paternal
Grandmother
DYes (age__)
o No
o Don't know
Maternal Aunts
DYes
(age__)
o No
o Don't know
Paternal Aunts
DYes
(age__)
DO No
o Don't know
Maternal
Grandfather
DYes (age__)
o No
o Don't know
Maternal
Grandmother
DYes (age__)
Paternal
Grandfather
DYes (age__)
o No
o Don't know
o No
o Don't know
Maternal Uncles
DYes
(age__)
o No
o Don't know
Maternal Aunts
DYes
(age__)
o No
o Don't know
Paternal Uncles
DYes
(age__)
o No
o Don't know
Paternal Aunts
DYes
(age__)
o No
o Don't know
Maternal
Grandfather
DYes (age__)
Paternal
Grandfather
DYes (age__)
o No
o Don't know
o No
o Don't know
Maternal Uncles
DYes
(age__)
o No
o Don't know
Paternal Uncles
DYes
(age__)
o No
o Don't know
o
o
No
Don't know
Paternal
Grandmother
DYes (age__)
I
InstilullOllal Rc\-ic\\ Bo.1rd (CUMClRB)
IRB"
-_.
~- -­
AAAE3306
Approval Dale
----~--a-.-rnrf;alS -.3JfJl----~
Columbia UniverSltv Medical Center
I
12129:09
11)0",0
I
2
.­
Mother
Sisters
Father
o Yes (how
Type 1
Diabetes
(insulin
dependent)
DYes
(ag e__)
o No
o Don't
know
Type 2
Diabetes
(non-insulin
dependent)
DYes
(age__)
o No
o Don't
know
Asthma
Known
genetic
condition
DYes
(age__)
o No
o Don't
know
DYes
(age_ _)
o No
o Don't
know
DYes
(age__)
o No
ODon't
know
DYes
(age__)
o No
ODon't
know
DYes
(ag e_ )
o No
ODon't
know
DYes
(age_ _)
o No
o Don't
know
many
sisters? _'
ages
o No
DDon't know
o Yes (how
many
sisters? _'
ages
o No
ODon't know
o Yes (how
many
sisters? _'
ages
o No
ODon't know
o Yes (how
many
sisters? _'
ages
o
o
No
Don't
know
'-----Maternai------·.--Paternal
--Maternal Aunts
Brothers
Grandnarents
Grandnarents
and Uncles
----_._---_. - - - ~ - - -----,--- ~.,..,-,-,,_._.•.. _---,_......,-_..._."--,.
Maternal
Paternal
Maternal Aunts
o Yes (how
Grandmother
Grandmother
0 Yes
DYes (age__) 0 Yes (age__) (age__)
many
o No
0 No
0 No
brothers? _'
ages
o Don't know
0 Don't know
0 Don't know
Maternal
Paternal
Maternal Uncles
Grandfather
Grandfather
o No
0 Yes
o Don't know DYes (age__) 0 Yes (age__) (age__)
o No
0 No
0 No
o Don't know
0 Don't know
0 Don't know
Maternal
Paternal
Maternal Aunts
o Yes (how
0 Yes
Grandmother
Grandmother
DYes (age__) 0 Yes (age__) (age__)
many
o No
0 No
0 No
brothers? _'
ages
o Don't know
0 Don't know
0 Don't know
Maternal
Paternal
Maternal Uncles
o No
Grandfather
Grandfather
0 Yes
o Don't know o Yes (age__) 0 Yes (age__) (age__)
o No
0 No
0 No
o Don't know
0 Don't know
0 Don't know
Maternal
Paternal
Maternal Aunts
o Yes (how
Grandmother
Grandmother
0 Yes
DYes (age__) 0 Yes (age__) (age__)
many
o No
0 No
0 No
brothers? _'
ages
o Don't know
0 Don't know
0 Don't know
Maternal
Paternal
Maternal Uncles
o No
Grandfather
Grandfather
0 Yes
o Don't know DYes (age__) 0 Yes (age__) (age__)
No
0 No
0 No
o Don't know
0 Don't know
0 Don't know
Paternal
Maternal
Maternal Aunts
Grandmother
Grandmother
DYes
o Yes (how
DYes
0 Yes
(age__)
(age__)
(age__)
many
o No
o
No
0 No
brothers? _'
o
Don't know
ages
o Don't know
0 Don't know
Maternal
Paternal
Maternal Uncles
o No
Grandfather
Grandfather
DYes
o Don't know 0 Yes
0 Yes
(age_ _)
(age__)
(age__)
o
No
0 No
o No
o
Don't know
0 Don't know
o Don't know
Paternal Aunts
and
-Uncles
--­
Paternal Aunts
DYes
(age__)
o No
o Don't know
Paternal Uncles
DYes
(age__)
o No
o Don't know
Paternal Aunts
DYes
(age__)
o No
o Don't know
Paternal Uncles
DYes
(age__)
o No
o Don't know
Paternal Aunts
DYes
(age__)
o No
o Don't know
Paternal Uncles
DYes
(age__)
o No
o Don't know
o
Paternal Aunts
DYes (age_ _)
o No
o Don't know
Paternal Uncles
DYes (age_ _)
o No
o Don't know
i
lnslllulional Review Board (CUMCIRB)
IRS.
AAAE3306
Approval Date
IrHl.la!$
?j!Jl - -
Uj5iie6iileate -"70311'0
Columbia University Medical Center
12129109
I
3
If your child's biological father was not born in the US,
in what year did he move to the US?
SOCIODEMOGRAPHIC
What is your child's date of birth?
----
MONTH
/_-- /_--­
DAY
D Don't Know
YEAR
Do you consider your child Spanish, Hispanic or
Latino?
Which of the following best
describes your child's ethnicity?
(Multiple answers permitted)
D Cuban
D Dominican
D
Mexican/Mexican American/Chicano
DYes
-­
D Puerto Rican
D Other Spanish/Hispanic/Latino:
D Don't Know
D No
D Don't Know
How do you describe your child's race? (Multiple
answers permitted)
D White
D Black/African American
D American Indian/Alaskan Native
D Asian Indian
D Chinese
D Filipino
D Japanese
D Korean
D Vietnamese
D other Asian:
_
D Native Hawaiian
D Guamanian/Chamorro
D Samoan
D Other Pacific Islander:- - - - - ­
D Other race: - - - - - - - - - ­
D Don't Know
Please provide general information about place of
birth for your child and his/her biological parents.
Was your child born in the United States?
DYes
D No _ _ What Country?
_
D Don't know
Was his/her biological mother born in the US?
DYes
D No _ _ What Country?
_
D Don't know
What is your child's biological mother's year of birth?
Year
D Don't Know
If your child's biological mother was not born in the
US, in what year did she move to the US?
Year
D Don't Know
Was your biological father born in the US?
DYes
D No _ _ What Country?
D Don't know
_
What is your child's biological father' year of birth?
Year
D Don't Know
Year
D Don't Know
What was the highest level of education your child's
mother completed?
D None
D Some grade school (grades 1 to 7)
D Grade school graduate (grade 8)
D Some high school (grade 9-12)
D High school graduate or GED
D Post high school training other than college (vocational,
technical, etc.)
D Some college or associates degree
D College graduate
D Master's degree /some graduate school
D Doctoral degree
D Don't know
Which of the following best describes your child's
mother's current employment status?
D Employed
D Unemployed, looking for work
D Laid off 'from job
D Going to school
D Homemaker, not working outside home
D Disability
D Other:
_
D Don't Know
If your child's mother is currently employed, what
is her CURRENT occupation?
D Don't Know
[Skip next question]
If currently unemployed, what was her LAST
occupation?
D Don't Know
What was the highest level of education your child's
father completed?
D None
D Some grade school (grades 1 to 7)
D Grade school graduate (grade 8)
D Some high school (grade 9-12)
D High school graduate or GED
D Post high school training other than college (vocational,
technical, etc.)
D Some college or associates degree
D College graduate
D Master's degree /some graduate school
D Doctoral degree
D Don't know
Which of the following best describes your child's
father's current employment status?
D Employed
D Unemployed, looking for work
D Laid off from job
D Going to school
D Not working outside home
D Disability
D Other:
D Don't Know
If your child's father is currently employed, what is
his CURRENT occupation?
D Don't Know
[Skip next question]
If currently unemployed, what was his LAST
occupation?
D Don't Know
Here is a list of salary ranges. Please select the
category that best describes your yearly household
income from salaries and all other sources.
D Up to $10,000
D Up to $15,000
D Up to $20,000
D Up to $25,000
D Up to $30,000
D Up to $35,000
D Up to $50,000
D Up to $75,000
D Up to $100,000
D Up to $150,000
D Up to $200,000
DOver $200,000
D Don't Know
During the pregnancy with this child, please check
off any of the following items that occurred:
D Use of alcohol
How many drinks/week?
_
During which weeks in the pregnancy?
_
D Smoking
How many cigarettes/day?
_
_
During which weeks in the pregnancy?
D Use of over the counter medication(s)
What medication(s)?
_
During which weeks in the pregnancy?
_
D Use of prescription medication(s)
What medication(s)?
_
_
During which weeks in the pregnancy?
D Infection
What infection?
- - - - - - - - - -_During which weeks in the pregnancy?
D Diabetes
D Abnormalities on blood tests
What abnormality?
D Abnormalities on prenatal ultrasounds
What abnormality?
D Premature delivery
At how many weeks in the pregnancy?
Instilutional Rc\'ic\\ Bmnd (CUMC IRS)
IRBIII
AAAE3306
Approval Dale
Initials
Ell;liratiooOale
Columbia Universil Medical Center IRB
12129109