Eligibility Screener

Form Approved:

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx

Interviewer___________________ Date_____________

INITIAL ELIGIBILITY SCREENING INSTRUMENT FOR WOMEN INTERESTED IN PARTICIPATING IN THE NAVAJO BIRTH COHORT STUDY

The purpose of this study is to look into community concerns about whether exposure to uranium mining and milling waste affects the outcome of pregnancies and the development of Navajo children. The proposed research will provide a public health benefit through education on environmental prenatal risks and provide earlier assessment and referral for identified developmental delays. Finally, the results of this study will provide the first Navajo-Nation-wide documentation of birth outcomes and developmental delays. Information gathered and analyzed will be provided to the tribe and Navajo Area Indian Health Service which may be used to improve future birth outcomes and services.

If you are interested in participating we would like to ask some questions to make sure you are eligible.

1. Do you currently live or work, or have you in your lifetime, lived or worked on the Navajo Nation at least 5 years or more?  Yes  No  Don’t Know

[If “no”, person is NOT eligible; STOP HERE]

2. Are you 14 to 45 years old as of today?  Yes  No  Don’t Know

[If “no”, person is NOT eligible; STOP HERE]

3. Are you pregnant?  Yes  No  Don’t Know

[If “no”, person is NOT eligible; STOP HERE]

4. Where (what location) do you plan to deliver?

 Chinle Comprehensive Health Care Facility

 Ft. Defiance Indian Hospital

 Gallup Indian Medical Center

 Kayenta Health Center

 Northern Navajo Medical Center (i.e., Shiprock Hospital)

 Tuba City Regional Health Care Corporation

[If none of these, person is NOT eligible; STOP HERE]

Public reporting burden of 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).

5. How did you determine you are pregnant?

 Missed period?

Date of last menstrual period? / /

MM DD YY

 Home pregnancy test?

 Clinic visit?

What clinic? How determined?

 Urine HCG

 Blood HCG

 Ultrasound

 Don’t know

 Saw medicine person

_{ Other?}

[If none of these, person is NOT eligible; STOP HERE]

6. What is your estimated delivery date?

/ / MM DD YYYY

7. Are you willing to have baby followed for the first year, until they are 12 months old?

 Yes  No

[If none of these, person is NOT eligible; STOP HERE]

8. Are you still interested in participating in this study?  Yes  No

_{If no -}

 Just not interested

 Don’t have the time

 My parents / partner / family won’t let me or would be mad if I did

 Spiritual belief

_{ Other}

If she is interested and eligible collect information below and schedule a time to do the consent and enrollment survey.

_Name:

_Address:

_{Phone number:}

_{Appointment time:}

_{Appointment location:}

If she is not interested at this time, provide phone number and contact information and let her know that she may change her mind before baby is born.