Child Survey Module B: Health Status Now I would like to ask you some questions about any symptoms [Child’s name] may have experienced after the incident. Within 24 hours of the incident, did [Child’s name] have any symptoms of an illness? Yes No Go to next module I’m going to ask you some questions about symptoms that could be related to the [Chemical] that was released. Fill out the table provided below. Repeat B2 for one symptom and check the boxes that apply before asking about the next symptom. Did [Child’s Was Was Is [Child’s name] experience [Child’s name] [Child’s name]’s name] still [Symptom] within experiencing [Symptom] worse experiencing 24- hours of the [Symptom] before after the incident? [Symptom]? incident? If yes, go the incident? If Continue to iv (if Repeat i for next to ii. If no, repeat i yes, go to iii. If listed); otherwise; symptom. for next symptom. no, go to iv. repeat i for next symptom. Symptom Yes No Yes No Yes No Yes No Irritation/pain/ burning of eyes Increased tearing Blurred vision/double vision Runny nose Burning nose or throat Burning lungs Increased salivation Ringing of the ears Difficulty swallowing Odor on breath (Gasoline or other, specify) Headache Dizziness or lightheadedness Loss of consciousness/fainting Seizures Numbness, pins and needles, or funny feeling in arms or legs Confusion Difficulty concentrating Weakness of arms Weakness of legs Muscle twitching
Child Survey Module B: Health Status Now I would like to ask you some questions about any symptoms [Child’s name] may have experienced after the incident. Within 24 hours of the incident, did [Child’s name] have any symptoms of an illness? Yes No Go to next module I’m going to ask you some questions about symptoms that could be related to the [Chemical] that was released. Fill out the table provided below. Repeat B2 for one symptom and check the boxes that apply before asking about the next symptom. Did [Child’s name] experience [Symptom] within 24- hours of the incident? If yes, go to ii. If no, repeat i for next symptom. Was [Child’s name] experiencing [Symptom] before the incident? If yes, go to iii. If no, go to iv. Was [Child’s name]’s [Symptom] worse after the incident? Continue to iv (if listed); otherwise; repeat i for next symptom. Is [Child’s name] still experiencing [Symptom]? Repeat i for next symptom. Symptom Yes No Yes No Yes No Yes No Irritation/pain/ burning of eyes Increased tearing Blurred vision/double vision Runny nose Burning nose or throat Burning lungs Increased salivation Ringing of the ears Difficulty swallowing Odor on breath (Gasoline or other, specify) Headache Dizziness or lightheadedness Loss of consciousness/fainting Seizures Numbness, pins and needles, or funny feeling in arms or legs Confusion Difficulty concentrating Weakness of arms Weakness of legs Muscle twitching