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1、精品范文模板 可修改删除撰写人：_日 期：_上海预调查A pilot survey in general population, ShanghaiQ0001调查点代码:Surveyed site number: 每个空格处填写一个数字Q0002调查对象编号:Respondent ID:Q0003是初次调查还是再次调查？ 1.初次 2.再次Is this the initial or retest interview? 1.Initial 2. RetestQ0003a如果是再次调查，请指明两次调查间的间隔天数：(天)If retest interview, indicate number of
2、 days between initial and retest: (Days)Q0004调查员编号Interviewer IDQ0005调查员姓名Interviewer name_ 请用大写英文字母填写Q0006调查完成日期(年/月/日)Date of finish(Year/Month/Day)/Q0007调查结果： 1.完成 2.部分完成 3.失访Final result 1. Finished 2. Part finished 3. MissingQ0008督导员审核日期(年/月/日)Date of audit(Year/Month/Day)/督导员签字Signature of Sup
3、ervisor_AstraZeneca R&D Mlndal第二军医大学卫生统计学教研室2005.10知情同意书Consent Form尊敬的参与者：您好。您已被随机地选为本次研究的调查对象，我们将对您作有关调查。本次研究是阿斯利康国际药业公司与第二军医大学卫生统计学教研室联合开展的一项预调查研究，由专业人员进行调查。您所提供的信息仅用于了解影响您健康的一些问题，整个调查约需30分钟。您提供的信息不会泄漏给任何人，只用于研究目的。您的姓名、地址和其他个人信息将从调查表中删去，仅用代码与您的姓名和您的回答相联系，单从调查表不能认出是您本人。调查组在必要时可能会再次与您联系。您的参与是自愿的，并且
4、可以在调查过程中退出。您可以拒绝回答调查问卷中的任何一个问题。在调查过程中，如果您有任何问题，可直接问调查员或直接与第二军医大学卫生统计学教研室的督导员联系。签字表示您已了解您在本次调查中需要做的事情并愿意参加本次调查。Dear Participant,You have been randomly selected to be part of this survey and we would, therefore, like to interview you. This survey is a pilot study conducted by the AstraZeneca Internati
5、onal Pharmaceutical Company and Department of Health Statistics, Second Military Medical University (SMMU), and will be carried out by professional interviewers. The information you provide will only be used to understand the main things that affect your health. The interview will take approximately
6、 30 minutes. The information you provide is totally confidential and will not be disclosed to anyone. It will only be used for research purposes. Your name, address, and other personal information will be removed from the questionnaire, and only a code will be used to connect your name and your answ
7、ers without identifying you. The Survey Team may contact you again only if it is necessary to complete the information on the survey.Your participation is voluntary and you can withdraw from the survey after having agreed to participate. You are free to refuse to answer any question that is asked in
8、 the questionnaire.If you have any questions about this survey you may ask interviewer or contact Principal Investigator of Department of Health Statistics, SMMU.Signing this consent indicates that you understand what will be expected of you and are willing to participate in this survey.调查对象签名： 日期：S
9、ign of respondent: _ Date: /联系电话：_第一部分：基本情况Part I: General Information)填写答案处AnswerQ1001姓名(请用汉语拼音填写) Full name (Please fill with English)_ 横线处请用大写字母填写。Q1002性别: 1-女性 2-男性 Sex: 1-Female 2-Male 每个空格处填写一个数字，带有小数者请四舍五入。Q1003年龄 (岁) Age (yrs)Q1003a如果记不清具体年龄，请选择您所在的年龄段：1. 1819岁 2. 2029岁 3. 3039岁4. 4049岁 5. 5
10、059岁 6. 6069岁 7. 70+If you dont know/dont want to tell me your age could you tell me the age range: 1. 1819yrs 2. 2029yrs 3. 3039yrs4. 4049yrs 5. 5059ysr 6. 6069ysr 7. 70+Q1004体重(公斤) Weight(kg)Q1005身高(厘米) Height(cm)Q1006婚姻状况: 1-已婚 2-未婚Current marital status: 1- Married 2-UnmarriedQ1007最高学历: 1-小学以下 2
11、-小学 3-初中 4-高中 5-大专/大学 6-硕士 7-博士The highest level of education: 1-Less than primary school 2-Primary school completed 3-Secondary school completed 4-High school (or equivalent) completed 5-College / pre-university / University completed 6-Master degree 7-Doctor degreeQ1008您总共接受过多少年学校教育(包括复读时间)？How ma
12、ny years of school education have you completed (including repeated grades)?Q1009民族(请用汉语拼音填写) Nationality (Please fill with English)_Q1010职业: 1-公务员 2-专业技术人员(军人除外) 3-工人4-农、林、牧、渔业从业者 5-服务行业人员 6-在校学生 7-军人Current job: 1-Government employee 2-Professional or technician (excluding armed forces) 3-Blue-col
13、lar worker 4-Agricultural or fisheries Worker5-Personal services, marketing, or sales 6-Student in school 7-Armed forcesQ1011家庭月收入: 1-1999元以下 2-20004999元 3-50009999元 4-10000元以上Total income of family per month: 1-less than 1999 Yuan 2-20004999 Yuan3-50009999 Yuan 4-10000 Yuan or aboveQ1012吸烟情况:1-不吸 2
14、-15支/天 3-610支/天 4-1115支/天 5-1620支/天 6-21支/天 以上Do you currently smoke?1-No 2-15pieces/day 3-610pieces/day 4-1115pieces/day 5-1620pieces/day 6-21pieces/day or aboveQ1012a如果您吸烟，请说明您大概吸了多少年了？If you smoke, for how many years are you have been smoking?Q1013饮酒情况: 1-不饮酒 2.-每月少于4次 3-每周至少一次 4-每天至少一次Do you currently drink?: 1-No 2-Less than 4 times per month3-At least 1 time per week 4-At least 1 time per dayQ1013
