Form 10 Form

Neighbor Information (Eligibility) Form

INTRODUCTION: Hello, I’m (NAME) and am working with (LOCAL STUDY CENTER) on a large study of children’s health for the National Institutes of Health (SHOW ID BADGE). The study is called the National Children’s Study. I have been trying to contact the people who live at (TARGET DU ADDRESS).

	Neighbor
Is there anyone living at (TARGET DU ADDRESS)?	YES 1 NO 2 (END) DK 7 (END) RF 8 (END)
Are there any women ages 18 to 49 living there?	YES 1 NO 2 DK 7 (END) RF 8 (END)
When is a good time to find someone at home? ENTER ALL THAT APPLY	Time: a.m. p.m. Days: Before noon: 12 noon -4 pm: 4 pm- 8pm:
In case my supervisor wants to check my work, I would like to have your name, address, and phone number.	Name: Address: Phone:

END: Thank you for your time.

Comments: _________________________________________________________________

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