反流性食管炎（GERD）人群患病情况上海预调查问卷 - BioMed Central.DOC

Q0001 调查点代码: Surveyed site number: 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. Retest Q0003a 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 days between initial and retest: (Days) Q0004 调查员编号 Interviewer ID Q0005 调查员姓名 Interviewer name ______________ 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. Missing Q0008 督导员审核日期(年/月/日) Date of audit(Year/Month/Day) // 督导员签字 Signature of Supervisor ______________ AstraZeneca RD M?lndal 第二军医大学卫生统计学教研室 2005.10  尊敬的参与者： 您已被随机地选为调查，我们将对您作有关调查。本是开展的一，由专业人员进行调查。您所提供的信息仅用于了解影响健康的问题，整个调查约需0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。在调查过程中，如果您有任何问题，可直接问或直接与督导员联系。 签字表示您愿意参加本调查。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 International 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 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 answers 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 the ques