反流性食管炎gerd人群患病情况上海预调查问卷.docxVIP

文件编码（TTU-UITID-GGBKT-POIU-WUUI-0089） 文件编码（TTU-UITID-GGBKT-POIU-WUUI-0089） 反流性食管炎GERD人群患病情况上海预调查问卷 PAGE A pilot survey A pilot survey in general population, Shanghai Q0001 调查点代码: Surveyed site number: 每个空格处填写一个数字 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 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 ______________ 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) 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) 知情同意书Consent FormThis 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 知情同意书 Consent Form 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 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： Sign of respondent: ______________