Study Name
* must provide value
Participant ID
* must provide value
Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Borneo Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Cook Islands Costa Rica Croatia Cuba Curacao Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland Gabon Gambia Georgia Germany Ghana Greece Greenland Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Israel Italy Ivory Coast Jamaica Japan Java Jordan Kazakhstan Kenya Kiribati Kosovo Kurdistan Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Malawi Malaysia Mali Mauritania Metropolitan Denmark Metropolitan France Metropolitan Norway Metropolitan Portugal Metropolitan Spain Mexico Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Niue Fekai North America North Korea Northern Ireland Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Poland Qatar Republic of Congo Republic of Ireland Romania Russia Rwanda Saint Kitts-Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Scotland Senegal Serbia Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Sri Lanka Sudan Sumatra Suriname Swaziland Sweden Switzerland Syria Tahiti Tajikistan Tanzania Tawain Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United States of America Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wales Western Sahara Yemen Yugoslavia (formerly) Zambia Zimbabwe
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Male
Female
Not Specified
Unknown
Other
Pediatric age category at enrollment
* must provide value
Gestational (0 - 45 weeks)
Neonate (0 hours - 28 days)
Infant (29 days - 12 months)
Toddler (13 months to 4 years)
School age (5 to 12 years)
Adolescent (13 to 18 years)
Estimated gestational age (EGA) in weeks, days
* must provide value
How was gestational age determined?
Classification of birth weight
Low birth weight (< 2,500 g)
Very low birth weight (< 1,500 g)
Extremely low birth weight (< 1,000 g)
0 - 24 hours 25 to 72 hours 3 to 7 days 8 to 28 days
Hispanic or Latino
Not Hispanic or Latino
Not Specified
Other
Unknown
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
More than One Race
Unknown or Not Reported
White
Does the study participant have any past medical history?
* must provide value
Yes No Unknown N/A
Tuberculosis
* must provide value
Yes No Not Specified N/A
Yes No Not Specified N/A
Yes No Not Specified N/A
Yes No Not Specified N/A
Diabetes (gestational, non-gestational)
* must provide value
Yes No Not Specified N/A
Hypertension (acute, chronic, pregnancy-induced)
* must provide value
Yes No Not Specified N/A
Autoimmune or other immune mediated illness
* must provide value
Yes No Not Specified N/A
Anemia
* must provide value
Yes No Not Specified N/A
Cardiac disease
* must provide value
Yes No Not Specified N/A
Miscarriages, Spontaneous Abortions
* must provide value
Yes No Not Specified N/A
Previous surgeries on reproductive tract (Myomectomy, removal of septum, fistula repair, cone biopsy, CS, repaired rupture, cervical cerclage)
* must provide value
Yes No Not Specified N/A
Previous pregnancy complication (placental abruption, placenta previa, PPH etc)
* must provide value
Yes No Not Specified N/A
Any blood/blood product transfusion in the 90 days prior to delivery?
* must provide value
Yes No Not Specified N/A
Please document the following:Â
Any vaccine administered 90 days prior to delivery Any medication taken 90 days prior to delivery This section is linked to RxNorm, a standardized medication database that provides normalized names for generic and branded clinical drugs. If you are unable to find the appropriate option in RxNorm, please specify at the bottom of this section.
Has the study participant's mother taken any medications or received any vaccines in the 90 days prior to delivery?
* must provide value
Yes No Not Specified N/A
Up to 20
Medication or Vaccination 1
Type to begin searching
Medication or Vaccination 2
Type to begin searching
Medication or Vaccination 3
Type to begin searching
Medication or Vaccination 4
Type to begin searching
Medication or Vaccination 5
Type to begin searching
Medication or Vaccination 6
Type to begin searching
Medication or Vaccination 7
Type to begin searching
Medication or Vaccination 8
Type to begin searching
Medication or Vaccination 9
Type to begin searching
Medication or Vaccination 10
Type to begin searching
Medication or Vaccination 11
Type to begin searching
Medication or Vaccination 12
Type to begin searching
Medication or Vaccination 13
Type to begin searching
Medication or Vaccination 14
Type to begin searching
Medication or Vaccination 15
Type to begin searching
Medication or Vaccination 16
Type to begin searching
Medication or Vaccination 17
Type to begin searching
Medication or Vaccination 18
Type to begin searching
Medication or Vaccination 19
Type to begin searching
Medication or Vaccination 20
Type to begin searching
Was there any information you were not able to include for any medications entered above?
* must provide value
Yes
No
Please specify any additional information you would like to note for medications entered above.
Were you unable to enter any medications?
* must provide value
Yes No
Please specify any medications that could not be entered.
Does the study participant have any medical history?
* must provide value
Yes No Not Specified N/A
Yes No Not Specified N/A
Underweight, malnutrition
* must provide value
Yes No Not Specified N/A
Obesity
* must provide value
Yes No Not Specified N/A
Syndromic disorder (including genetic disorders such as Down's, Edward's (Trisomy 18), Patau etc.)
* must provide value
Yes No Not Specified N/A
Born preterm
* must provide value
Yes No Not Specified N/A
Major congenital defect
* must provide value
Yes No Not Specified N/A
Other general history?
* must provide value
Yes No Not Specified N/A
Yes No Not Specified N/A
Yes No Not Specified N/A
Gastrointestinal history? * must provide value
Yes No Not Specified N/A
Renal/Urological/Genital history? * must provide value
Yes No Not Specified N/A
Yes No Not Specified N/A
Yes No Not Specified N/A
Yes No Not Specified N/A
Head, Eyes, Ears, Nose, and Throat history? * must provide value
Yes No Not Specified N/A
Yes No Not Specified N/A
Immunodeficiency syndrome - please specify
Yes No Not Specified N/A
Please specify any cancer history
Yes No Not Specified N/A
Yes No Not Specified N/A
Infectious Disease history? * must provide value
Yes No Not Specified N/A
Please document the following:
Any vaccine administered 30 days prior to enrollment Any medication taken 30 days prior to enrollment Any immunosuppressant/ blood product received 90 days prior to enrollment. Any experimental product taken in the past year. Any chemotherapy, radiation therapy, or biological ever taken. This section is linked to RxNorm, a standardized medication database that provides normalized names for generic and branded clinical drugs. If you are unable to find the appropriate option in RxNorm, please specify at the bottom of this section.
Is the study participant currently taking any medications?
* must provide value
Yes No Not Specified N/A
How many medications/vaccinations?
* must provide value
Up to 20
Medication or Vaccination 1
Type to begin searching
Medication or Vaccination 2
Type to begin searching
Medication or Vaccination 3
Type to begin searching
Medication or Vaccination 4
Type to begin searching
Medication or Vaccination 5
Type to begin searching
Medication or Vaccination 6
Type to begin searching
Medication or Vaccination 7
Type to begin searching
Medication or Vaccination 8
Type to begin searching
Medication or Vaccination 9
Type to begin searching
Medication or Vaccination 10
Type to begin searching
Medication or Vaccination 11
Type to begin searching
Medication or Vaccination 12
Type to begin searching
Medication or Vaccination 13
Type to begin searching
Medication or Vaccination 14
Type to begin searching
Medication or Vaccination 15
Type to begin searching
Medication or Vaccination 16
Type to begin searching
Medication or Vaccination 17
Type to begin searching
Medication or Vaccination 18
Type to begin searching
Medication or Vaccination 19
Type to begin searching
Medication or Vaccination 20
Type to begin searching
Was there any information you were not able to include for any medications entered above?
* must provide value
Yes
No
Please specify any additional information you would like to note for medications entered above.
Were you unable to enter any medications?
* must provide value
Yes
No
Please specify any medications that could not be entered.
Was dietary data collected from the study participant?
* must provide value
Yes
No
Do you follow a specific diet?
None
Vegetarian diet
Vegan diet
Ketogenic diet
Low-carbohydrate diet
Low-fat diet
Low-cholesterol diet
DASH diet
Mediterranean diet
Intermittent fasting
Other
Don't Know
Instructions for Interviewer:
Fill in the food groups based on the information recorded above. For food groups not mentioned, ask if any food item from the group was consumed.
1. Cereals Examples: corn/maize, rice, wheat, sorghum, millet or any other grains or foods made from these (e.g. bread, noodles, porridge or other grain products)
Yes
No
Don't Know
2. Vitamin A rich vegetables and tubersExamples: pumpkin, carrots, squash, or sweet potatoes that are orange inside + other locally available vitamin-A rich vegetables (e.g. red sweet pepper)
Yes
No
Don't Know
3. White tubers and rootsExamples: white potatoes, white yams, white cassava, or other foods made from roots
Yes
No
Don't Know
4. Dark green leafy vegetablesExamples: dark green/leafy vegetables, including wild ones + locally available vitamin-A rich leaves such as amaranth, cassava leaves, kale, spinach etc.
Yes
No
Don't Know
5. Other vegetablesExamples: other vegetables (e.g. tomato, onion, eggplant), including wild vegetables
Yes
No
Don't Know
6. Vitamin A rich fruitsExamples: ripe mangoes, cantaloupe, apricots (fresh or dried), ripe papaya, dried peaches + other locally available vitamin A-rich fruits
Yes
No
Don't Know
7. Other fruitsExamples: other fruits, including wild fruits
Yes
No
Don't Know
8. Organ meat (iron-rich)Examples: liver, kidney, heart or other organ meats or blood-based foods
Yes
No
Don't Know
9. Flesh meatsExamples: beef, pork, lamb, goat, rabbit, wild game, chicken, duck, or other birds
Yes
No
Don't Know
10. EggsExamples: chicken, duck, guinea hen or any other egg
Yes
No
Don't Know
11. Fish and seafoodExamples: fresh or dried fish or shellfish
Yes
No
Don't Know
12. Legumes, nuts, and seeds Examples: beans, peas, lentils, nuts, seeds or foods made from these (e.g. hummus, peanut butter)
Yes
No
Don't Know
13. Milk and milk products Examples: milk, cheese, yogurt or other milk products
Yes
No
Don't Know
14. Oils and fats Examples: oil, fats or butter added to food or used for cooking
Yes
No
Don't Know
15. SweetsExamples: sugar, honey, sweetened soda or sugary foods such as chocolates, candies, cookies and cakes
Yes
No
Don't Know
16. Spices and other condimentsExamples: spices(black pepper, salt), condiments (soy sauce, hot sauce), coffee, tea. alcoholic beverages OR local examples
Yes
No
Don't Know
Did you eat anything (meal or snack) outside the house yesterday?
Yes
No
Don't Know
The dietary diversity score is calculated by counting the number of different food groups consumed (Yes/No) during the 24-hour period.
View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation View equation Dietary Diversity Score *Note: This will be directly calculated in REDCap during data entry
View equation Has the child been breastfed?
Yes
No
Don't Know
During the period of breastfeeding, was the child given anything other than breast milk?
Yes
No, child was exclusively breastfed
Don't Know
Infant Formula
Water or sugar water
Other fluids
Don't Know
Other fluids - please specify
How long was the child breastfed for (months)?
At what age were solid foods introduced (months)?
Did the study participant receive a transplant?
* must provide value
Yes
No
The survey is complete, thank you!
Date of Transplant (YYYY-MM-DD)
Today Y-M-D
Single Organ
Multiple Organs
Type of Multiple Organ Transplant
Heart-Lung
Liver-Kidney
Kidney-Pancreas
Other
Type of Single Organ Transplant
Heart
Lung - Single
Lung - Bilateral
Liver - Deceased Donor
Liver - Living Donor
Pancreas
Kidney - Deceased Donor, Single
Kidney - Deceased Donor, En-Bloc
Kidney - Living, Related
Kidney - Living, Unrelated
Intestinal
Vascular Composite Allograft
Type A
Type B
Type O
Type AB
Don't Know
Negative
Positive
Don't know/not done
Hepatitis B surface antigen
Hepatitis B surface antibody
Hepatitis B core antibody
Previous history of transplant?
Yes
No
Don't Know
Primary diagnosis for transplant (primary cause of organ failure)
Type A
Type B
Type O
Type AB
Don't Know
Negative
Positive
Don't Know
Hepatitis B surface antigen
Hepatitis B surface antibody
Hepatitis B core antibody
Was patient sensitized at the time of transplantation (defined as cPRA>20%)?
Yes
No
Unknown
Methylprednisolone
Basiliximab
Anti-thymocyte globulin
Alemtuzumab
Maintenance (at time of hospital discharge)
Cyclosporine
Tacrolimus
Rapamycin/sirolimus
Everolimus
Mycophenolate
Prednisone
Belatacept
Other
Rituxumab
Bortezomib
Plasmaphoresis
Other
Did the patient ever have an episode of allograft rejection?
Yes
No
If yes, date of rejection:
Today Y-M-D
Acute Cellular Rejection
Antibody Mediated rejection
Acute Cellular Rejection - additional notes
Antibody Mediated Rejection - additional notes