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Healthy Homes Project

By Louise Gonzales,2014-05-06 03:18
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Healthy Homes Project

    Healthy Homes Project Intake / Screening Form

Date / Time of inquiry: _____________________

My name is David Story. I’m the coordinator for the Healthy Homes Project. Thank you for

    inquiring about the Project.

To be in the study, you must live in the target area, have a child diagnosed with asthma

    between the ages of 4 & 12, live in a 1 4 family home and you must sign a consent form.

Name: _____________________________________

    Phone #: (H) ____________________ (W)______________________ Street Address: __________________________________________

    Zip Code: 02119, 02120, 02121, 02122, 02124, 02125 Number of apartments in building: 1 2 3 4 more (not eligible)

    Is the building owner occupied? Yes No

    Do you own the home? Yes No

    Number of children in home: 1 2 3 4 5 6 more

    Number of asthmatics in home: 1 2 3 4 5 6 more

    Is one of them 4 12 years old? Yes No (not eligible)

    Is he /she currently in any other asthma study? No Yes Which study?

    _______________________________________________________________________

How did you hear about the project? _________________________________________

If ineligible: I’m sorry, but you are not eligible. The Office of Environmental Health can still

    provide a home evaluation for you, as resources become available though you will not be

    eligible for the intensive follow-up and financial assistance. Would you still like the OEH to

    arrange a home evaluation? Yes No

    If eligible: Now I would like to explain how the study works. The Healthy Homes Project is a study of how changes in the home can reduce the risk for

    asthma, lead poisoning and injuries for children. Participants will receive a home inspection

    for asthma risks, lead poisoning hazards, and childhood injury hazards, and will make

    recommendations based on this inspection.

Two evaluators will come to your home. The visit will take about two hours. They will be

    walking through all the rooms of your house. They may go into your basement. They may

    take pictures with your permission. Someone will be asking you questions about your home,

    neighborhood, health and housekeeping practices. We’ll also ask permission to review your

    child / children’s medical records. At the visit, you’re child will receive a simple breathing test, so your child must be available during the visit. Also, you will receive an asthma diary that we would like for you to complete. The inspectors will be leaving air sampling bags overnight. Someone will have to be available so that they can pick these up the next day. Will someone be available the next day? Yes No

    Recommendations will be made based on this visit (they will be sent to you in the mail). We will call you to make sure that you received these. Some of these will require little or no money to be put into place. For those recommendations that do involve construction and renovation, we can provide technical assistance working with your landlord / we can help identify a contractor and sources of financial assistance. This study does not pay for

    renovations or repairs and can not guarantee that you will qualify for the loans.

    Six months later, you will receive a short survey in the mail to complete and mail back. After one year, we will schedule another home visit with you to ask some survey questions, collect asthma diaries and give your child another breathing test. Again, they will need permission to review your children’s medical records. Altogether, your entire involvement should take about 6 hours over the course of a year. Are you still interested in participating? Yes No

    I will send an outline and ICF for the project to your home. You must discuss this with all the members of your household and they must all agree to participate. Will you do this?

     Yes No

    When are you available to have us come to your home? ______________________ Do you have any other questions?

Reminder phone calls: ____________________ ____________________

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Notes: _______________________________________________________________

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