Confidential Sickle Cell DB Version 7 Page 1 of 7 Extended Demographics
Research Subject ID Research ID ______
Patient Details
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Country where the data was collected ? Albania Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Congo Democratic Rep of Congo Cote d'Ivoire Djibouti Egypt Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Guinea Guinea-Bissau Kenya Lesotho Liberia Libyan Arab Jamahiriya Madagascar Malawi Mali Mauritania Mauritius Mayotte Morocco Mozambique Namibia Niger Nigeria Reunion Rwanda Saint Helena Sao Tome and Principe Senegal Seychelles Sierra Leone Somalia South Africa South Sudan Sudan Swaziland Tanzania Togo Tunisia Uganda Western Sahara Zambia Zimbabwe Other
If not an African Country, please specify ______
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Type of study the patient is enrolled in Meta-Analysis Systematic Review Randomized Controlled Trial Cohort Study Case-control Study Cross-sectional study Case Reports and Series Animal Research Studies Test-tube Lab Researc Treatment Research Prevention Research Diagnostic Research Screening Research Quality of Life Research Genetic studies Epidemiological studies Phase I Clinical trials Phase II Clinical trials Phase III Clinical trials Phase IV Clinical trials Ideas, Editorials, Opinions
Date on which the registration was done. (MM/DD/YYYY) ______
Age in months at the time of the interview/test/sampling/imaging. ______
Socio-Demographics What is the highest grade or level of school you have None completed or the highest degree you have received? Nursery Primary Secondary University Refused Don't Know (PX011001 | phenx_current_educational_attainment)
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Please select the income currency for your country. UAE dirham Afghan afghani Albanian lek Armenian dram Netherlands Antillean guilder Angolan kwanza Argentine peso Australian dollar Aruban florin Azerbaijan manat Bosnia and Herzegovina convertible mark Barbadian dollar Bangladeshi taka Bulgarian lev Bahraini dinar Burundi franc Bermudian dollar Brunei dollar Bolivian boliviano Brazilian real Bahamian dollar Bhutanese ngultrum Botswana pula Belarusian ruble Belize dollar Canadian dollar Congolese franc Swiss franc Chilean peso Chinese Yuan Renminbi Colombian peso Costa Rican colon Cuban peso Cape Verdean escudo Czech koruna Djiboutian franc Danish krone Dominican peso Algerian dinar Egyptian pound Eritrean nakfa Ethiopian birr Fijian dollar Falkland Islands pound Pound sterling Georgian lari Guernsey Pound Ghanaian cedi Gibraltar pound Gambian dalasi Guinean franc Guatemalan quetzal Guyanese dollar Hong Kong dollar Honduran lempira Croatian kuna Haitian gourde Hungarian forint Indonesian rupiah Israeli new shekel Manx pound Indian rupee Iraqi dinar Iranian rial Icelandic krona Jersey pound Jamaican dollar Jordanian dinar 06/08/2019 9:44am Japanese yen projectredcap.org Kenyan shilling Kyrgyzstani som Cambodian riel Comorian franc North Korean won South Korean won Kuwaiti dinar Cayman Islands dollar Kazakhstani tenge Lao kip Lebanese pound Sri Lankan rupee Liberian dollar Lesotho loti Libyan dinar Moroccan dirham Moldovan leu Malagasy ariary Macedonian denar Myanmar kyat Mongolian tugrik Macanese pataca Mauritanian ouguiya Mauritian rupee Maldivian rufiyaa Malawian kwacha Mexican peso Malaysian ringgit Mozambican metical Namibian dollar Nigerian naira Nicaraguan cordoba Norwegian krone Faroese krona Nepalese rupee New Zealand dollar Omani rial Peruvian sol Papua New Guinean kina Philippine peso Pakistani rupee Polish zloty Paraguayan guarani Qatari riyal Romanian leu Serbian dinar Russian ruble Rwandan franc Saudi Arabian riyal Solomon Islands dollar Seychellois rupee Sudanese pound Swedish krona Singapore dollar Saint Helena pound Sierra Leonean leone Somali shilling Surinamese dollar South Sudanese pound Sao Tome and Principe dobra Syrian pound Swazi lilangeni Thai baht Tajikistani somoni Turkmen manat Tunisian dinar Tongan pa'anga Turkish lira Trinidad and Tobago dollar New Taiwan dollar Tanzanian shilling Ukrainian hryvnia Ugandan shilling United States dollar Uruguayan peso Uzbekistani som Venezuelan bolivar Vietnamese dong Vanuatu vatu Samoan tala Central African CFA franc East Caribbean dollar SDR (Special Drawing Right) West African CFA franc CFP franc Yemeni rial South African rand Zambian kwacha Other
Poverty Scale Based on a $1.9 per day poverty line and 366 days, an annual income for the poverty line is calculated to be $695.4.
Was your total annual family income from all sources Less less than the poverty threshold or more? More Refused Don't know (PX011101 | phenx_annual_family_income)
What was your best estimate of the total income of all family members from all sources, before taxes, ______in the last year? (PX011101 | phenx_annual_family_income)
What is your current employment status? Working Now Only Temporarily Laid Off, Sick Leave Or Maternity Leave Looking For Work, Unemployed Retired Disabled, Permanently Or Temporarily Keeping House Student Other (PX011301 | phenx_current_employment_status)
If other current employment status ______(PX011301 | phenx_current_employment_status)
Marital status of primary caregiver Married Widowed Separated Divorced Never married Living with partner Refused to answer Other (PX0840101)
If other marital status, please specify. ______Confidential Page 7 of 7
Relationship of primary caregiver to patient Mother Father Niece or nephew Aunt or uncle First cousin Second cousin Unknown cousin Grandparent Great grandparent Great great grandparent Great aunt or uncle Great great aunt or great great uncle Foster parent Other; explain below (PX0840101)
Relationship of primary caregiver to patient if "Other" was selected. ______(PX0840101)
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