ࡱ> :<9 ;bjbj (aa&T T $$$$$8888p |,87"!!!!!!!,#&!$!$$!L$$!! Z!pV12!!"07"F!!'!'(Z!$Z!@!!7"!'T :    Identifying Information 1. Date of birth ___________ 2. Sex: _______male _______female 3. Ethnic background: 4. Marital Status: a. single b. married c. divorced d. separated e. remarried 5. Education grad degree some college some grad school high school degree college degree some high school 6. Occupation: 7. Approximate yearly household income: 8. Religion: 9. Siblings Name DOB M/F ICN (Y/N) Alive (Y/N) ICN # Days Sub Age DX 10. Children: Date of birth M/F ICN? Sibling Interview Guide A. Childhood What is your earliest memory when you think back to your childhood? Can you tell me a little about your childhood? Can you talk a little about your father/mother when you were growing up? Can you tell me a little about each of your siblings when you were growing up? B. Family Communication (if sib was alive) Can you tell me a little about your understanding as a child of your sibling's condition? If you had questions about it, was there anyone you could bring them to? How did you see the illness? Did you ever talk about it with a sibling? A parent? Anyone? Did you ever wish you were sick too? Did you ever worry you might be sick too? Were you pretty active physically as a child? Any accidents as a child? Ever feel any resentment? Do you feel you were overprotected as a child? C. Experience in the ICN (if sib was alive) Can you tell me a little about your experience when your sibling was in the nursery? How long was he/she in the nursery? What disorder did he/she have? Did you visit your brother or sister? How much do you remember? Did you have any dreams or nightmares? Did you have questions about what was happening? Was there anyone you could ask? Can you tell me a little about your experience with the physician? Do you feel that you had interaction with any medical staff? How was that for you? Do you have any recollection of any advice or guidance from the medical staff? Any hurtful comment? D. Experience of Death (if sib was alive) Would you tell me a little about your experience when your sibling died? Were you present when the baby died? Was there any final ritual? Did you go? What were your feelings at that time? How did your parents react? Do you feel your relationship with your parents changed in any way following the death? Can you tell me a little about your feelings after the death? Was there anyone you could go to for support? How do you feel your parents handled the loss? How do you think they mourned? E. Parental Mourning of Child (if sib was not alive at time baby was) When did you learn that there was a baby in your family who had died? How old were you when you found out? How did you find out? What were your feelings at that time? How do you feel your parents handled the loss? How do you think they mourned? Are there any photos of the baby in the house? Where are they? F. Possible Current Difficulties l. Anxiety Do you worry about anything? What? What do you do to relax? How do you feel when you go to the doctor for a checkup? When you visit a friend in the hospital? Do you worry about your children's health? How do you react when they get sick? Do you worry about your own health? Do you think you'll live to a ripe old age? Do you have muscular aches and pains? Have you ever had any illness? Respiratory problems? Cardiovascular difficulties? Ulcers? Rashes? Skin problems? Allergies? Headaches? Difficulty sleeping? Nightmares? How often? 2. Depression Do you ever get depressed? How often? How long does it last? How much do you think about your sibling/sister now? (If sibling died) Are you aware of the time of the year he/she died - how is that for you each year? Can you tell me a little about your work? Do you have any trouble concentrating? Do you have any hobbies? Can you tell me a little about your friendships? How often do you see your friends? Do you have a close intimate relationship with someone? Can you tell me a little about that relationship? 3. Guilt Do you feel guilty about anything? How often? How do you feel when bad things happen to friends? How do you feel when good things happen to you? How do you feel about taking on responsibility? Is there anything you still wish you had done differently with your sibling? Is this something you think about a lot? What was your reaction when you first heard of this study? G. Recommendations Do you have any suggestions for helping siblings of babies in the ICN? Anything you can think of that would have made it easier for you to cope with this experience?     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