|
FORM NAME |
FORM DETAILS |
| Form A: Screening |
Includes infant and mother medical history summarized from
chart review to determine eligibility.
Collected: Once prior to study enrollment.
Annotated Form A |
| Form B: Family Interview |
Includes sociodemographic family information, maternal
obstetric and medical history prior to and during pregnancy, and
labor and delivery information.
Collected: Once after enrollment into the study.
Annotated Form B |
| Form C: Infant Medical History |
Includes neonatal information such as newborn physical
measurements and gestational age, vaccinations and medications used
prior to hospital discharge, systems functioning, infections and
surgeries, and post discharge information including medical history,
nutritional status, feeding history and sleeping habits.
Collected: Once after enrollment into the study.
Annotated Form C
|
| Form D: Post-Enrollment Medical Follow-Up |
Includes interim medical information such as infant
vaccination schedule, nutritional status, feeding and sleeping
habits, as well as medications taken by the mother.
Collected: One month post enrollment, and at 44, 50, 56, 64, 72,
80 and 92 weeks PCA.
Annotated Form D
|
| Form E: CHIME Hospitalization Review Form |
Includes information about infant hospitalization such
as dates of hospitalization, reason for hospitalization, diagnostic
studies, treatment and final diagnosis at discharge from the
hospital.
Collected: Following EACH hospitalization, including any
pre-enrollment hospitalizations which may have followed initial
newborn discharge.
|
| Form H1: CHIME Monitor Confidence Scale |
Includes caregiver self-reported confidence in
performing activities related to home monitoring such as applying
electrodes, remembering to turn monitor on, etc.
Collected: One month post enrollment and at 44, 50, 56, 64, 72,
80, and 92 weeks PCA.
Annotated Form H1 |
| Form H2-Weekly: Weekly Contact |
Includes information about the preceding week
including monitor alarms, medical contacts, outpatient diagnostics,
illnesses not requiring medical attention, medication use, daycare
and home monitor use.
Collected: Weekly |
| Form H2-Missed: Missed Weekly Contact |
Includes information about weeks during which the
H2-Weekly Form was not successfully completed such as infant
breathing, hospitalization and outpatient diagnostics.
Collected: For each time interval where an H2-Weekly was not
completed.
Annotated Form H2-Missed |
| Form H2-Phone: CHIME Phone Contact Report |
Includes information pertaining to the CHIME montitor
and technical support provided such as family concerns, responses to
these concerns, and any supplies necessary for continued monitoring.
Collected: Weekly, if a visit was not completed, and anytime
phone contact was made regarding support for the CHIME monitor.
Annotated Form H2-Phone |
| Form H2-Visit: CHIME Monitor Report |
Includes information pertaining to the CHIME montitor
and technical support provided such as family concerns, responses to
these concerns, and any supplies necessary for continued monitoring.
Collected: Weekly, if phone contact was not completed, and
anytime a visit was necessary to provide support for the CHIME
monitor.
Annotated Form H2-Visit
|
| Form H4: CHIME Monitor Satisfaction Scale |
Includes caregiver report of satisfaction with the
CHIME monitor such as ease of use and/or problems that may have
arisen.
Collected: One month post enrollment and at 44, 50, 56, 64, 72,
80 and 92 weeks PCA. |
| Form H6: CHIME Knowledge Evaluation Form |
Includes 10 multiple choice questions regarding
caregiver's knowledge of home monitoring.
Collected: After initial montiro training, at the one month
post-intake visit, and at the second medical follow-up visit. |
| Form I: CHIME Completion of Monitoring Form |
Includes information such as the dates of home monitor
use, the reason for monitor ending and participation in other
studies.
Collected: Once after study has been completed. |
| Form K1: Feelings About Parenting |
Includes information such as the caregiver's feelings
toward the infant, toward restrictions imposed by parenting
and toward their own competence in the parental role.
Collected: At 44 and 56 weeks PCA. |
| Form K2: Parenting Stress Index Depression Subscale |
Includes measures of parental depression and emotional
availability as well as information pertaining to prior family
problems.
Collected: At 44, 56 and 92 weeks PCA. |
| Bayley Mental Scale Record Form |
Includes assessments of infant sensory-perceptual
activity such as object constancy, memory, learning, problem solving
and verbal ability.
Collected: At 44, 56, and 92 weeks PCA. These dates are adjusted
for pre and post maturity. |
| Bayley Motor Scale Record Form |
Includes assessments of infant muscle control, gross
motor coordination and fine motor coordination.
Collected: At 44, 56, and 92 weeks PCA. These dates are adjusted
for pre and post maturity. |
| Bayley Behavior Rating Scale Record Form |
Includes assessments of infant attitude, interest,
emotion, energy, activity, and response to stimuli.
Collected: At 44, 56, and 92 weeks PCA. These dates are adjusted
for pre and post maturity. |
| Feeding Scale |
Includes assessment of parent-child interaction during
an observed feeding session.
Collected: At 44, and 56 weeks PCA. |
| Teaching Scale |
Includes assessment of parent-child interaction during
an observed teaching situation where the parent is asked to teach
the child a specific task.
Collected: At 92 weeks PCA. |
