Parental Survey of Sickle Cell Trait
Child’s Information
Folder no............................................... Sex.................................DOB/Age...........................................
Informant: (a.) Mother
(b.) Father
Informant’s Information
1. Age
2. Highest educational level
a. None
b. Primary
c. Secondary
d. Tertiary
3. Occupation……………………………
4. Employment
a. Civil Servant
b. Private Company
c. Self-employed
d. Unemployed
5. Religion
a. Christian
(Denomination…………..)
b. Muslim
c. Others
6. Tribe………………………………
7. Are you aware of your Hb genotype?
a. Yes
b. No
8. If yes, what is it
a. AA (normal genotype)
b. AS (carrier genotype)
c. SS (sickle cell anemia)
d. Others
9. When did you become aware your
genotype?
a. Knowledge sake
b. School admission requirement
c. Employment requirement
d. Marriage
e. Child with SS in family
f. Pregnancy
g. Others (Specify………………...
Spouse’s Information
1. Age
2. Highest educational level
a. None
b. Primary
c. Secondary
d. Tertiary
3. Occupation……………………………
4. Employment
a. Civil Servant
b. Private Company
c. Self-employed
d. Unemployed
5. Religion
a. Christian
(Denomination…………..)
b. Muslim
c. Others
6. Tribe………………………………
7. Is he/she aware of his/her Hb genotype?
a. Yes
b. No
8. If yes, what is it
a. AA (normal genotype)
b. AS (carrier genotype)
c. SS (sickle cell anemia)
d. Others
9. When did your spouse become aware of
his/her genotype?
a. Knowledge sake
b. School admission requirement
c. Employment requirement
d. Marriage
e. Child with SS in family
f. Pregnancy
g. Others (Specify…………………
Question 1: How does someone get SCT?
a. You are born with it (It's hereditary)
b. You get it from a blood transfusion
c. You can get it some other way
d. Don't know/refused
Question 2: To inherit sickle cell disease, both parents must have at least one sickle cell disease gene
a. True
b. False
Question 3: How would someone know if they have sickle cell trait?
a. Get their blood tested
b. Get their urine tested
c. Don’t know
Question 4: it is important to know if you have sickle cell trait even if you don’t have any symptoms
a. True
b. False
Question 5: People who have sickle cell trait considered to have a mild form of sickle cell disease?
a. True
b. False
Question 6: People who have sickle cell trait have symptoms of sickle cell disease?
a. True
b. False
Question 7: Thinking about sickle cell trait, among Nigerians you would say it affects…
a.
b.
c.
d.
1 in every 4
1 in every 12
1 in every 50
1in every 100
Question 8: If two people with sickle cell trait marry, the chance that their child will have sickle cell
disease is
a.
b.
c.
d.
1 in 4 (25%)
1 in2 (50%)
1 in 1 (100%)
Zero chance
Question 9: What would you say is the best way to increase awareness about SCT?
a.
b.
c.
d.
e.
f.
Mail out written information or pamphlet
Hold informational meetings in community
Publicize on TV
Publicize on radio
Distribute a video or CD about SCD
Other
Question 10: Have you ever heard of C-trait?
a. Yes
b. No
If yes: Question 11: Do you know, if you, personally, have C-trait?
a. Yes have it
b. No don't have it
c. Don't know/refused
Question 12: Have you ever heard of b-thalassemia trait?
a. Yes
b. No
If yes: Question 13: Do you know, if you, personally, have Beta-thalassemia trait?
a. Yes have it
b. No don't have it
c. Don't know/refused
Age at and Factors affecting Age at Diagnosis of Sickle Cell Anaemia
1. Hospital/ID number..........................................................................................................................
2. Present
age.......................................................................................................................................
3. Gender.............................................................................................................................................
.
4. Age
at
diagnosis
of
SCA.....................................................................................................................
5. Mother’s
age
at
diagnosis.................................................................................................................
6. Mother’s educational status at diagnosis.........................................................................................
7. Mother’s
occupation
at
diagnosis.....................................................................................................
8. Father’s
age
at
diagnosis..................................................................................................................
9. Father’s
occupation
at
diagnosis......................................................................................................
10. Father’s educational status at diagnosis..........................................................................................
11. Number of times genotype was done before confirming SCA........................................................
12. Event
(s)
diagnosis.....................................................................................................
necessitating
13. Are parents aware of their genotype before marriage? (Yes)
14. Parent’s genotype before patient’s diagnosis
(No)
(No idea)
Father........................... Mother.........................
15. Any prenatal counselling following knowledge of genotype? (Yes)
(No)
(No idea)
16. Any other immediate family member with HbS genotype (SCA) diagnosed before index patient?
(Yes)
(No)
(No idea)
17. Any extended family member with SCA diagnosed before index patient? (Yes)(No)(No idea)