PARENT/CAREGIVER DEMOGRAPHICS OPT Form 96 V1 (1-3) MAR 06 Clinical Unit: Form Date: -- MonthDayYear attach PID label here Patient ID: -- Coordinator Code: II 2. Is the primary caregiver Hispanic? 1 Yes2 No 4. What is the primary caregiver's highest education level completed? 1 Less than 7 th grade 2 7 th, 8 th, 9 th grade 3 10 th or 11 th grade 4 high school graduate or GED 5 Partial college (at least 1 year or completed specialized training) 6 College or university graduate 7 Graduate degree 3. What is the primary caregiver's primary language? 1 English2 Spanish3 Other, describe: ____________________________ 1. What is the race of the primary caregiver? Ask the subject “Which of these groups describes your ancestry?” Check ALL that apply. (Use definitions only if subject seems unsure about a group.) 1 Caucasian / White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. 1 American Indian or Alaska Native A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliations or community attachment. 1 Asian A person having origins in any of the original peoples of the Far East, Southeast Asia including the Philippine Islands, or the Indian subcontinent. 1 Black or African American A person having origins in any of the black racial groups of Africa. 1 Native Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. 1 Don't know/Refused 5. What is the primary caregiver's occupation? __________________________________________________________ 6. Is the primary caregiver the child's biological mother? 2 No 1 Yes SKIP TO Q Visit:

OPT Form 96 V1 (2-3) MAR 06 Patient ID: -- II 9. What is the biological mother's primary language? 1 English2 Spanish3 Other, describe: ____________________________ 7. What is the race of the biological mother? 1 Caucasian / White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. 1 American Indian or Alaska Native A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliations or community attachment. 1 Asian A person having origins in any of the original peoples of the Far East, Southeast Asia including the Philippine Islands, or the Indian subcontinent. 1 Black or African American A person having origins in any of the black racial groups of Africa. 1 Native Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. 1 Don't know 11. What is the biological mother's occupation? __________________________________________________________ 8. Is the biological mother Hispanic? 1 Yes2 No3 Don't know 10. What is the biological mother's highest education level completed? 1 Less than 7 th grade 2 7 th, 8 th, 9 th grade 3 10 th or 11 th grade 4 high school graduate or GED 5 Partial college (at least 1 year or completed specialized training) 6 College or university graduate 7 Graduate degree 8 Don't know 12. Is the primary caregiver the child's biological father? 2 No 1 Yes SKIP TO Q. 18

OPT Form 96 V1 (3-3) MAR 06 Patient ID: -- II 15. What is the biological father's primary language? 1 English2 Spanish3 Other, describe: ____________________________ 13. What is the race of the biological father? 1 Caucasian / White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. 1 American Indian or Alaska Native A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliations or community attachment. 1 Asian A person having origins in any of the original peoples of the Far East, Southeast Asia including the Philippine Islands, or the Indian subcontinent. 1 Black or African American A person having origins in any of the black racial groups of Africa. 1 Native Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. 1 Don't know 17. What is the biological father's occupation? __________________________________________________________ 14. Is the biological father Hispanic? 1 Yes2 No3 Don't know 16. What is the biological father's highest education level completed? 1 Less than 7 th grade 2 7 th, 8 th, 9 th grade 3 10 th or 11 th grade 4 high school graduate or GED 5 Partial college (at least 1 year or completed specialized training) 6 College or university graduate 7 Graduate degree 8 Don't know 18. Are there other adults living in the same household with the child? (other than the primary caregiver, biological mother and biological father) 2 No 1 Yes 18a. Please list relationship to child and occupation relationship occupation 1. __________________________ ____________________________________________ 2. __________________________ ____________________________________________ 3. __________________________ ____________________________________________ 4. __________________________ ____________________________________________ 5. __________________________ ____________________________________________