At what time points would you like diet assessed? Which method of intake reporting will be used? 3d diet diary Food Frequency Questionnaire (FFQ) 24h diet recall Photographic food records Other. Specify: 6C. If you are requesting diet instruction or nutrition education, please answer the following: What is the goal of the counseling session? (e.g. weight loss, improve compliance, standard disease dietary education, etc.) At what time points will counseling be provided? How long will each counseling session last? Will you be providing core materials for counseling sessions? Yes No If no, please explain what materials will be required Are the core materials obtained from/based on guidelines from a professional or government Yes No organization (e.g. ADA, Obesity Society, USDA, If yes, please name the organization and source of the NIH)? materials 6D. If you are requesting growth assessment, please answer the following: What specific parameters would you like Height Bicep skinfold measured? (Check ALL that apply) Weight Sub-scapula skinfold Mid-arm circumference Hip skinfold Waist circumference Hip circumference Tricep skinfold Other. Specify: At what time points would you like growth assessed? Do you require the calculation of z-scores? Yes No If yes, please explain 6E. If you are requesting indirect calorimetry (IC), please answer the following: What is the purpose of IC? RMR Fat oxidation Carbohydrate oxidation Other. Specify: At what time points would you like IC performed? Does you study population have any special medical needs that might hinder IC data collection Yes No (e.g. spasticity, TPN, etc)? If yes, please explain 6F. If you are requesting physical activity (PA) questionnaires, please answer the following: What specific parameters are you trying to assess? (e.g. habitual activity, adherence to protocol, etc) At what time points would you like PA assessed? Which method of measurement will be used? PDPAR Activity Diary 24h activity recall Specify: 6G. If you are requesting DEXA, please answer the following: What specific parameters are you trying to assess? (e.g. fat mass, lean mass, change in fat mass, etc.) At what time points would you like DEXA performed?
At what time points would you like diet assessed? Which method of intake reporting will be used? 3d diet diary Food Frequency Questionnaire (FFQ) 24h diet recall Photographic food records Other. Specify: 6C. If you are requesting diet instruction or nutrition education, please answer the following: What is the goal of the counseling session? (e.g. weight loss, improve compliance, standard disease dietary education, etc.) At what time points will counseling be provided? How long will each counseling session last? Will you be providing core materials for counseling sessions? Yes No If no, please explain what materials will be required Are the core materials obtained from/based on guidelines from a professional or government organization (e.g. ADA, Obesity Society, USDA, NIH)? Yes No If yes, please name the organization and source of the materials 6D. If you are requesting growth assessment, please answer the following: What specific parameters would you like measured? (Check ALL that apply) Height Weight Mid-arm circumference Waist circumference Tricep skinfold Bicep skinfold Sub-scapula skinfold Hip skinfold Hip circumference Other. Specify: At what time points would you like growth assessed? Do you require the calculation of z-scores? Yes No If yes, please explain 6E. If you are requesting indirect calorimetry (IC), please answer the following: What is the purpose of IC? RMR Fat oxidation Carbohydrate oxidation Other. Specify: At what time points would you like IC performed? Does you study population have any special medical needs that might hinder IC data collection (e.g. spasticity, TPN, etc)? Yes No If yes, please explain 6F. If you are requesting physical activity (PA) questionnaires, please answer the following: What specific parameters are you trying to assess? (e.g. habitual activity, adherence to protocol, etc) At what time points would you like PA assessed? Which method of measurement will be used? PDPAR Activity Diary 24h activity recall Specify: 6G. If you are requesting DEXA, please answer the following: What specific parameters are you trying to assess? (e.g. fat mass, lean mass, change in fat mass, etc.) At what time points would you like DEXA performed?
Attachment-U-TCH-Pediatric-CTRC-Utilization-Form.docx