2 survey

Appendix E – Pregnancy Screener – NCS Automated Self-response Study

PREGNANCY SCREENER (AUDIO CASI) VISIT: SECTION PS

PS002P Westat, a research company in Rockville, Maryland is conducting survey research for the National Institute of Child Health and Human Development to test questions for an upcoming national survey. Over time, we hope to improve the health of children in our community and across the nation with this research. The purpose of this project is to compare different ways to collect information from women of child-bearing age.

CONTINUE……………………………………………………1

PS003 OK, {(NAME)}, let me confirm some information I have about {(NAME)/you}. How old {are you/is (NAME)}?

|__|__|

REFUSED 9--97

DON’T KNOW 9--98

PS004 What is your address?

{StreetNo} {PreDir} {Street} {StTypeID} {PostDir} {UnitTypeID} {UnitNo}

{City}, {State} {Zip} {ZipPlus4}

REFUSED 9 -- 97

DON’T KNOW 9 -- 98

PS012 Now, I have a few questions for you to answer on your own that will help decide how you can take part in this study. This should take about 5 minutes. If you are chosen to be in one of the groups we need for the study now, I will give you more information to help decide whether you want to take part in it.

We are asking women questions about pregnancy, sexual activity and birth control. Some women may consider questions about sexual activity or birth control to be personal, so I’ll give you headphones to listen to the questions.  You will enter your responses into the computer by touching the screen.  This will allow you to answer questions in complete privacy. The computer will determine if you are able to take part in the Study.

{It would be best if you could sit down in a chair or at a table while answering these questions. Please let me know where a comfortable spot would be to get you set up.}

CONTINUE 1

PS013 OK, I’d now like to give you some important information. Answering these questions is your choice. You can skip over any question I ask or you can stop the interview at any time. Please keep in mind that your answers to these questions are very important. The information we collect from you is protected by law and we will keep all of it private. (IF NEEDED: You may be receiving government benefits, such as Social Security or Medicaid. Nothing will happen to those benefits if you decide not to take part in this study.) OK, let’s get started.

-Informed Consent

CONTINUE 1

START OF AUDIO CASI

Start Module 2, Section 1

PS016 The first three questions are practice questions and are not part of the study. They will help you learn how to use this computer. Remember that you need to press the ‘NEXT’ button after you have answered each question. If at any time you make a mistake answering a question, you can press the ‘CLEAR’ button to erase your answer and then select the correct answer. Press ‘NEXT’ to see the first practice question.

INTERVIEWER INSTRUCTION:

GIVE RESPONDENT HEAD PHONES AND ADJUST VOLUME.

PS017 What is your favorite soft drink?

RESPONDENT INSTRUCTION:

“Use the stylus to select your answer. Press ‘NEXT’ when you are done.”

Coke 1

Pepsi 2

Sprite 3

7-Up 4

Another soft drink 5

Do not drink soft drinks 6

REFUSED 9--97

DON’T KNOW 9--98

PS018 During a typical week, how many movies do you watch?

RESPONDENT INSTRUCTION:

“Use the keypad to enter the number. Enter 0 if none. Press ‘NEXT’ when you are done.”

|__|__|

REFUSED 9--97

DON’T KNOW 9--98

PS019 What is today’s date?

RESPONDENT INSTRUCTION:

“Enter today’s date, starting with the month, next the 2-digit day and lastly the 4-digit year. Press ‘NEXT’ when you are done.”

____/____/________ MM/DD/YYYY

REFUSED 9--97

DON’T KNOW 9--98

INVALID DATE MESSAGE: “You have entered an invalid date. Enter the date again.”

PS020 You have now completed the practice questions and are ready to begin the study questions. If at any point, you don’t know the answer to a question or prefer not to answer, press the ‘NEXT’ button without selecting an answer and follow the computer’s instructions. Let your interviewer know if you need help while answering the questions on your own.

When you are ready, press ‘NEXT’ to see the first question.

- ACASI instructions to respondent

Start Module 2, Section 2

PS021 Are you pregnant now?

Yes 1 (PS023)

No 2 (PS028)

REFUSED 9--97 (PS022)

DON’T KNOW 9—98 (PS022)

PS022 Do you think you are probably pregnant or not?

Yes, probably pregnant 1

No, probably not pregnant 2 (PS028)

REFUSED 9--97 (PS028)

DON’T KNOW 9--98 (PS028)

PS023 When is your baby due?

RESPONDENT INSTRUCTION:

“Enter your baby’s due date, starting with the month, next the 2-digit day and lastly the 4-digit year. Press ‘NEXT’ when you are done.”

____/____/________ MM/DD/YYYY (PS035)

REFUSED 9--97 (PS024)

DON’T KNOW 9—98 (PS024)

INVALID DATE MESSAGE: “You have entered an invalid date. Enter the date again.”

PS024 What was the first day of your last menstrual period?

RESPONDENT INSTRUCTION:

“Enter the month in which you started your last menstrual period, next the 2-digit day you started your last menstrual period and lastly the 4-digit year. Press ‘NEXT’ when you are done.”

____/____/________ MM/DD/YYYY (PS035)

REFUSED 9--97 (PS025)

DON’T KNOW 9—98 (PS025)

INVALID DATE MESSAGE: “You have entered an invalid date. Enter the date again.”

PS025 About how many weeks pregnant are you? If you’re not sure, please make your best guess.

RESPONDENT INSTRUCTION:

Enter the number of weeks using the keypad.

|___|___| (PS035)

REFUSED 9--97 (PS026)

DON’T KNOW 9--98 (PS026)

PS026 About how many months pregnant are you? If you’re not sure, please make your best guess.

RESPONDENT INSTRUCTION:

Enter the number of months using the keypad.

|___|___| (PS035)

REFUSED 9--97 (PS027)

DON’T KNOW 9--98 (PS027)

PS027 Are you currently in your 1^st, 2^nd, or 3^rd trimester?

1^ST Trimester (1 to 3 months pregnant) 1 (PS035)

2^ND Trimester (4 to 6 months pregnant) 2 (PS035)

3^RD Trimester (7 to 9 months pregnant) 3 (PS035)

REFUSED 9--97 (PS035)

DON’T KNOW 9--98 (PS035)

PS028 Are you currently trying to become pregnant?

Yes 1

No 2 (PS030)

REFUSED 9--97 (PS030)

DON’T KNOW 9--98 (PS030)

PS029 How many months have you been trying to become pregnant?

1 Month or less,………………………………… 1

2 Months,……………………………………….. 2

3 Months,……………………………………………. 3

4 Months,……………………………………….. 4

5 Months,……………………………………………. 5

6 Months,……………………………………….. 6

7 Months,……………………………………………. 7

8 Months,……………………………………….. 8

9 Months,……………………………………………. 9

10 Months,……………………………………….. 10

11 Months,……………………………………………. 11

12 To 24 Months, or………………………………………. 12

More Than 24 Months?………………………………. 13

REFUSED……………………………………………. 9--97

DON’T KNOW……………………………………….. 9--98

PS030 Do any of the following apply to you? Have you had:

• A hysterectomy,

• Both ovaries removed,

• Your tubes tied, or

• Gone through menopause?

Yes 1 (PS035)

No 2

REFUSED 9--97

DON’T KNOW 9--98

PS031 Because this study is enrolling women who may become pregnant, it is important to know if you are sexually active. Have you had sexual intercourse with a man in the past 3 months?

Yes 1

No 2 (PS035)

REFUSED 9--97 (PS035)

DON’T KNOW 9--98 (PS035)

PS032 Has your current sexual partner had a vasectomy?

Yes 1 (PS035)

No 2

Not sure 3

REFUSED 9--97

PS033 Now I have a few questions about birth control. The last time you had intercourse with a man, did you use any type of birth control or do anything to prevent pregnancy?

Yes 1

No 2 (PS035)

REFUSED 9--97 (PS035)

DON’T KNOW 9--98 (PS035)

PS034 What type of birth control did you use the last time you had intercourse with a man? You may select more than one answer.

RESPONDENT INSTRUCTION:

If you make a mistake, press the ‘CLEAR’ button to re-enter your answer.

Birth control pills 1

Condoms 2

Depo-Provera/ shots/ injections 3

Diaphragm/ cap/ shield 4

Natural family planning, including rhythm or safe

period by calendar, temperature, or

cervical mucus 5

Foam/ jelly/ cream/ insert 6

Female condom/ vaginal pouch 7

Patch/ Nuva ring 8

TODAY sponge 9

Withdrawal/ pulling out 10

IUD/ Coil/ Loop 11

Plan B/ “Morning After” pill 12

Norplant 13

Some other method 96

REFUSED 9--97

DON’T KNOW 9--98

PS035 Thank you for answering these questions. Please let your interviewer know that you are done.

IF PREGNANT (PS021=1) or STERILE (PS030=1) THEN GO TO PSCLSE5, ELSE CONTINUE

PS035A ENTER SECURITY CODE TO CONTINUE.

- Enter security code

END OF AUDIO CASI

Start Module 3, Section 1

PS036 Interviewer Repossess computer

• REARRANGE COMPUTER FOR INTERVIEWER USE.

• PUT AWAY EARPHONES AND DISPOSE OF EARPHONE COVERS.

• SELECT THE “CONTINUE” BUTTON AND THEN PRESS THE “NEXT” BUTTON WHEN YOU ARE READY TO CONTINUE. THE COMPUTER WILL RUN THE ALGORITHM AND ASSIGN THE WOMAN TO A GROUP.

CONTINUE 1

PS042 The computer will now process your answers. While we wait, these next few questions will help us to contact you again in the future.

CONTINUE 1

PS043 ASK OR VERIFY: What is your name?

_____________________ ___________________

FIRST NAME LAST NAME

REFUSED 9—97

DON’T KNOW 9—98

PS044 What is the best phone number to reach you?

INTERVIEWER INSTRUCTION:

ENTER PHONE NUMBER AND CONFIRM.

I__I__I__I – I__I__I__I – I__I__I__I__I (PS045)

REFUSED 9—97 (PS047)

DON’T KNOW 9—98 (PS046)

PS045 Is that your home, work, cell, or another phone number?

PSPhoneType - Home, work or cell phone

INTERVIEWER INSTRUCTION:

CONFIRM IF KNOWN.

HOME 1 (PS046)

WORK 2 (PS046)

CELL 3 (PS046J)

FRIEND/RELATIVE (SPECIFY: _________) 4 (PS046M)

OTHER (SPECIFY: ___________) 5 (PS045T)

REFUSED 9—97 (PS046)

DON’T KNOW 9—98 (PS046)

PS045M ENTER SPECIFIED FRIEND/RELATIVE.

_________________________________ (PS046J)

PS045T ENTER SPECIFIED OTHER PHONE.

_________________________________ (PS046J)

PS046 What is your cell number?

INTERVIEWER INSTRUCTION:

ENTER PHONE NUMBER AND CONFIRM.

ENTER CELL NUMBER 1

NO CELL NUMBER 9—90 (PS046J)

REFUSED 9—97 (PS047)

DON’T KNOW 9—98 (PS047)

PS046E ENTER CELL PHONE NUMBER.

I__I__I__I – I__I__I__I – I__I__I__I__I

PS046J What is another phone number where we can reach you?

INTERVIEWER INSTRUCTION:

ENTER PHONE NUMBER AND CONFIRM.

ENTER PHONE NUMBER 1

NO ADDITIONAL PHONE NUMBER 9—90 (PS047)

REFUSED 9—97 (PS047)

DON’T KNOW 9—98 (PS047)

PS046M ENTER ANOTHER PHONE NUMBER.

I__I__I__I – I__I__I__I – I__I__I__I__I

PS046 P Is that a home, work, cell, or another phone number?

INTERVIEWER INSTRUCTION:

CONFIRM IF KNOWN.

HOME 1 (PS047)

WORK 2 (PS047)

CELL 3 (PS047)

FRIEND/RELATIVE (SPECIFY: _________) 4

OTHER (SPECIFY: ___________) 5 (PS046W)

REFUSED 9—97 (PS047)

DON’T KNOW 9—98 (PS047)

PS046T ENTER SPECIFIED FRIEND/RELATIVE.

_________________________________

PS046W ENTER SPECIFIED OTHER PHONE.

_________________________________

PROGRAMMER INSTRUCTION:

ALLOW 30 CHARACTERS FOR SPECIFY FIELD

PS047 Is your mailing address the same as your street address?

YES…………………………………………………… 1 (PS048)

NO……………………………………………………. 2 (PS048)

REFUSED…………………………………………… 9--97 (PS048)

DON’T KNOW……………………………………… 9--98 (PS048)

PS048 What is your mailing address?

INTERVIEWER INSTRUCTION:

PROMPT AS NECESSARY TO COMPLETE INFORMATION

_____________________________________STREET/ PO BOX

_____________________________________CITY

|___|___| STATE |___|___|___|___|___| ZIP CODE

REFUSED ……….. .9—97

DON’T KNOW 9—98

PS049 What is your birthdate?

INTERVIEWER INSTRUCTION:

ENTER A TWO DIGIT MONTH, TWO DIGIT DAY AND A FOUR DIGIT YEAR.

____/____/________ MM/DD/YYYY

REFUSED 9--97

DON’T KNOW 9--98

PS050 Do you have an email address?

YES…………………………………………………… 1

NO……………………………………………………. 2 (PS058)

REFUSED…………………………………………… 9--97 (PS058)

DON’T KNOW……………………………………… 9--98 (PS058)

PS051 What is the best email address to reach you?

INTERVIEWER INSTRUCTION:

ENTER AND CONFIRM E-MAIL ADDRESS.

___________________________________

REFUSED 9—97(PS058)

DON’T KNOW 9—98 (PS058)

PS051m Is that your personal e-mail, work e-mail, or a family or shared e-mail address?

PERSONAL 1

WORK 2

FAMILY/SHARED 3

REFUSED 9--97

DON’T KNOW 9--98

PS058 Do you plan on moving from your present address within the next two months?

YES 1

NO 2 (PSCLSE6)

REFUSED 9--97 (PSCLSE6)

DON’T KNOW 9--98 (PSCLSE6)

PS059 Do you know where you will be moving?

YES 1

NO 2 (PS062)

REFUSED 9--97 (PS062)

DON’T KNOW 9--98 (PS062)

PS060 What is the address of your new home? We’ll contact you at your new address for the next part of this survey.

ADDRESS or PO BOX GIVEN 1

OUT OF THE COUNTRY 3 (PS062)

REFUSED 9--97 (PS062)

DON’T KNOW 9--98 (PS062)

PS061

INTERVIEWER INSTRUCTION: PROBE AND ENTER AS MUCH INFORMATION AS R KNOWS.

_____________________________________STREET ADDRESS / BOX

_____________________________________CITY

|___|___| STATE |___|___|___|___|___| ZIP CODE

PS062 Do you know when you will be moving?

YES 1

NO 2 (PSCLSE6)

REFUSED 9--97 (PSCLSE6)

DON’T KNOW 9--98 (PSCLSE6)

PS063 When will you move?

INTERVIEWER INSTRUCTION:

CONFIRM IF KNOWN.

ENTER AS MUCH AS R KNOWS.

ENTER A TWO DIGIT MONTH, TWO DIGIT DAY AND A FOUR DIGIT YEAR.

|___|___| |___|___| |___|___|___|___| (PSCLSE6)

REFUSED 9--97 (PSCLSE6)

DON’T KNOW 9--98 (PSCLSE6)

PSCLSE5 (APPLIES TO PREGNANT OR STERILE WOMEN) Thank you for coming to Westat to answer these questions. Here is your $50 in appreciation for the time and effort you spent today.

END INTERVIEW 1

PSCLSE6 (NON PREGNANT WOMEN) Thank you for your time. You have answered all of our questions for today. We will get back in touch with you in {6/12} weeks for the next part of the survey. That interview only has two to three more questions and you can do it at your convenience by:

(EMAIL GROUP) responding to an email from us.

(TEXT GROUP) responding to a text message we send you.

(IVR GROUP) phone, using our automated phone system.

You don’t need to come back here for that next part of the survey.

CONTINUE 1 (FIN)

FIN Here is the $50 for taking part in this research. We appreciate your help.

(EMAIL) We’ll send you a short email message in about a week to thank you again for coming in today. That will also give you a chance to see what an email from the Study will look like in your inbox before we...

(TEXT) If it’s okay with you, we’ll send you a text message in about a week to thank you again for coming in today. That will also give you a chance to see what a text message from the Study will look like in your phone before we…

(IVR) Our automated phone system will call you in about a week to thank you again for coming in today. That will give you a chance to see what the caller ID says and to hear what the system sounds like before we….

(ALL) contact you again {6/12} weeks from now to answer 2 or 3 more questions.

END INTERVIEW.

Public reporting burden for this collection of information is estimated to average 0.17 hours (10 minutes) per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0590). Do not return the completed form to this address.