Download:
pdf |
pdfAppendix A
Data Collection Forms
Appendix A.1
Questionnaires
A.1.1.a–1
Appendix A
INTRODUCTION AND CONSENT FOR ENUMERATION
IF SOMEONE WHO APPEARS TO BE UNDER 18 YEARS OLD ANSWERS THE
DOOR, ASK TO SPEAK WITH AN ADULT BEFORE PROCEEDING WITH THE
INTRODUCTION.
INTRODUCTION: Hello, I’m (DATA COLLECTOR NAME) from (LOCAL STUDY
CENTER). [SHOW ID BADGE.] We are conducting a large study about children’s
health for the National Institutes of Health. The study is called the National Children’s
Study. Recently you may have received a letter introducing the study. Did you receive our
letter?
[IF YES, R RECEIVED LETTER ASK: As mentioned in the letter, the purpose of the
study is to improve the health and well being of children, and we want to see if any of the
women in your household may be eligible to be in the study. Do you have any questions
about the study? [ANSWER ANY QUESTIONS AND HAND COPY OF BROCHURE.]
[IF NO, R DID NOT RECEIVE THE LETTER OR DOES NOT REMEMBER, HAND R
A COPY OF LETTER AND BROCHURE AND READ: Here is a copy of the letter and
our brochure. As mentioned in the letter, the purpose of the study is to improve the health
and well being of children, and we want to see if any of the women in your household may
be eligible to be in the study. The study will provide information that will form the basis
for improving child health care and policy for years to come. Your participation in the
study is voluntary and any information you give us will be kept confidential as required by
law. If you do not wish to participate or do not want to answer particular questions, this
will not result in any penalty or loss of benefits to you or your family.]
Are you a member of this household (and at least 18 years of age)?
IF NO, ASK TO SPEAK WITH ADULT HOUSEHOLD MEMBER AND RE-READ
INTRODUCTION.
IF NO ONE HOME 18 OR OLDER. Thank you for you time. When would be the best
time to reach someone who lives here who is 18 or older? LEAVE COPY OF STUDY
BROCHURE AND RECORD CONTACT INFORMATION IN EROC.
IF YES, START ENUMERATION INSTRUMENT.
Appendix A
A.1.1.a–2
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
Enumeration Visit: Section EN
EN001. First, I’d like to make sure I am at the correct address. Just to confirm, what is your address?
INTERVIEWER INSTRUCTION:
CONFIRM ADDRESS IF R PREVIOUSLY STATED IT IN INTERVIEW.
IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.
IF DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND
ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.
STREETNO: {StreetNo} PREDIR: {PreDir} STREET: {Street} STYPEID: {StTypeID} POSTDIR: {PostDir}
UNITYPEID: {UnitTypeID} UNITNO: {UnitNo}
CITY: {City}
STATE: {State}
ZIP CODE: {Zip} ZIPPLUS4: {ZipPlus4}
YES, CORRECT ADDRESS .................................................................... 1
YES (BUT WITH MINOR CORRECTIONS) ............................................. 2
NO (WRONG ADDRESS) ........................................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(EN004)
(EN003)
(EN002)
(ENCLOSE6)
(ENCLOSE6)
EN002. INTERVIEWER INSTRUCTION:
EXIT THE ENUMERATION AND SELECT THE CORRECT ADDRESS FROM YOUR ASSIGNMENT LIST. OR,
IF ADDRESS IS NOT ON LIST, EXPLAIN TO R THAT YOU HAVE WRONG ADDRESS AND THANK R FOR
HIS/HER TIME.
BOX EN00
GO TO EN_END.
EN003. INTERVIEWER INSTRUCTION:
CONFIRM CORRECTIONS WITH RESPONDENT. ACCEPT CORRECT FIELDS AND EDIT INCORRECT
FIELDS AS NECESSARY.
STREETNO: {StreetNo} PREDIR: {PreDir} STREET: {Street} STYPEID: {StTypeID} POSTDIR: {PostDir}
UNITYPEID: {UnitTypeID} UNITNO: {UnitNo}
CITY: {City}
STATE: {State}
ZIP CODE: {Zip} ZIPPLUS4: {ZipPlus4}
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.1.a–3
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
EN004. Is this a private residence?
INTERVIEWER INSTRUCTION:
SELECT IF KNOWN.
IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.
IF DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND
ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.
YES .......................................................................................................... 1 (EN012)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (ENCLOSE6)
DON’T KNOW .................................................................................... 9--98 (ENCLOSE6)
EN005. What type of place is this?
INTERVIEWER INSTRUCTION:
SELECT IF KNOWN.
IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.
IF DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND
ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.
SENIOR LIVING....................................................................................... 1
MILITARY BARRACKS ............................................................................ 2
RELIGIOUS QUARTERS ......................................................................... 3
ON-CAMPUS STUDENT HOUSING ........................................................ 4
CORRECTIONAL FACILITY .................................................................... 5
HOMELESS SHELTER ............................................................................ 6
GROUP HOME FOR MENTALLY ILL ...................................................... 7
JOB CORPS............................................................................................. 8
DOMESTIC VIOLENCE SHELTER.......................................................... 9
HALFWAY HOUSE .................................................................................. 10
OTHER..................................................................................................... 11
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
EN006. What is the name of this place?
INTERVIEWER INSTRUCTION:
CONFIRM SPELLING.
___________________________________
NAME OF GROUP LIVING QUARTERS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.1.a–4
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
EN007. Since this building has group living quarters, I will need to talk to a manager or administrator. Is a manager or
administrator available to speak with me now?
INTERVIEWER INSTRUCTION:
WAIT TO SPEAK WITH MANAGER OR ADMINISTRATOR BEFORE CONTINUING WITH NEXT QUESTION.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (ENCLOSE7)
REFUSED .......................................................................................... 9--97 (ENCLOSE7)
DON’T KNOW .................................................................................... 9--98 (ENCLOSE7)
EN008. I have a few questions to see if anyone here may be eligible for the study. Can women between the ages of 18
and 49 live here?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EN010)
REFUSED .......................................................................................... 9--97 (EN010)
DON’T KNOW .................................................................................... 9--98 (EN010)
EN009. Can a pregnant woman living here have a baby and continue to live here?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EN010. Are there any rooms at this address set aside for staff that would be considered their permanent residence?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX EN01)
REFUSED .......................................................................................... 9--97 (BOX EN01)
DON’T KNOW .................................................................................... 9--98 (BOX EN01)
EN010m. Can female staff between the ages of 18 and 49 live here?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX EN01)
REFUSED .......................................................................................... 9--97 (BOX EN01)
DON’T KNOW .................................................................................... 9--98 (BOX EN01)
EN010t. Can pregnant staff living here have a baby and continue to live here?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.1.a–5
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
BOX EN01
CHECK ITEM:
IF STAFF ARE NOT PERMANENT RESIDENTS AND NO WOMEN 18 –49
LIVING IN GROUP QUARTERS, GO TO ENCLOSE8.
IF STAFF ARE NOT PERMANENT RESIDENTS AND WOMEN WHO HAVE A
BABY CANNOT CONTINUE TO LIVE IN QUARTERS, GO TO ENCLOSE8.
IF STAFF ARE PERMANENT RESIDENTS AND STAFF CAN BE WOMEN 18–49
AND HAVE A BABY AND CONTINUE TO LIVE THERE AND NO WOMEN 18–49
LIVING IN GROUP QUARTERS, GO TO EN011.
IF STAFF ARE PERMANENT RESIDENTS AND STAFF CAN BE WOMEN 18–49
AND HAVE A BABY AND CONTINUE TO LIVE THERE AND WOMEN WHO
HAVE A BABY CANNOT CONTINUE TO LIVE IN QUARTERS, GO TO EN011.
OTHERWISE, GO TO EN012.
EN011. The residents living here are not eligible to take part in the Study, but the staff members who live here
permanently may be. I need to ask some additional questions. When answering the following questions think only
about the staff who live here and considers this their permanent residence.
EN012. IS RESPONDENT MALE OR FEMALE?
INTERVIEWER INSTRUCTION:
SELECT BY OBSERVATION.
MALE........................................................................................................
FEMALE ...................................................................................................
1
2
EN013. To determine whether anyone in this household is eligible for this important study, I’d like to get some information
about the people who live here. First, how many adults 18 or older live in this household, including any persons
who usually stay here but are temporarily away on business, vacation, in the hospital, on full-time active military
duty or students living temporarily away from home. Do not include anyone who is in a nursing home or other
institution. (Including yourself, what/What) is the total number of adults age 18 or older who live here?
INTERVIEWER INSTRUCTION:
IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.
IF DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND
ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.
|___|___|
NUMBER OF ADULTS IN HOUSEHOLD
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (ENCLOSE6)
9--98 (ENCLOSE6)
Appendix A
A.1.1.a–6
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
EN014. (Including yourself, how/How) many men 18 years or older live here?
INTERVIEWER INSTRUCTION:
IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.
IF DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND
ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.
|___|___|
NUMBER OF ADULT MALES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (ENCLOSE6)
9--98 (ENCLOSE6)
EN015. (Including yourself, how/How) many women 18 years or older live here.
INTERVIEWER INSTRUCTION:
IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.
IF DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND
ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.
|___|___|
NUMBER OF ADULT FEMALES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (ENCLOSE6)
9--98 (ENCLOSE6)
BOX EN02
CHECK ITEM:
IF ONE OR MORE WOMEN 18 OR OLDER LIVING IN HOUSEHOLD (EN015 >=
“1”) CONTINUE WITH EN016.
IF NO WOMEN 18 AND OLDER IN HOUSEHOLD (EN015 = “0”), GO TO EN027.
EN016. This study is looking at children’s health, including development before birth. We are interested in women
between 18 and 49. You just told me about the women 18 and older in this household, now think of only the
women 18 to 49. (Including yourself, how/How) many women 18 to 49 live here?
INTERVIEWER INSTRUCTION:
IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.
IF DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND
ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.
|___|___|
NUMBER OF WOMEN 18 TO 49
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (ENCLOSE6)
9--98 (ENCLOSE6)
Appendix A
A.1.1.a–7
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
BOX EN03
CHECK ITEM:
IF ONE OR MORE WOMEN 18–49 LIVING IN HOUSEHOLD (EN016 >= “1”),
CONTINUE WITH EN017.
IF NO WOMEN 18–49 LIVING IN HOUSEHOLD (EN016 = “0”), GO TO EN027.
EN017. Now, I have a few questions about the {woman who is/women who are} 18 to 49. This information will help us to
determine whether {she/they} may be eligible to take part in the National Children’s Study. {Let’s start with the
oldest woman first.}
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
HH WOMEN ENUMERATION GRID—QUESTIONS EN018–EN021
EN018. NAME: What is (her/your/the next woman’s) first name?
EN019. AGE: How old (is she/are you)?
EN020. RELATIONSHIP: How is she related to you?
EN021. PREGNANT: Since this is a study of children’s health, it is important to identify pregnant women. (Is she/Are you) pregnant?
INTERVIEWER INSTRUCTION:
NAME: COLLECT UNIQUE NAME.
RELATIONSHIP: IF R IS BEING ENUMERATED, SELECT “SELF” WITHOUT ASKING.
PREGNANT: COLLECT PREGNANCY STATUS. CONFIRM IF PREVIOUSLY REPORTED.
EN018. NAME
EN019. AGE
EN020. RELATIONSHIP
EN021. PREGNANT
__________________
UNIQUE FIRST NAME
|__|__|
AGE
REFUSED ........................... 9--97
DON’T KNOW...................... 9--98
REFUSED ............................ 9--97
DON’T KNOW ...................... 9--98
SELF ............................................... 1
WIFE ............................................... 2
DAUGHTER .................................... 3
GRANDDAUGHTER ....................... 4
MOTHER......................................... 5
GRANDMOTHER ............................ 6
SISTER ........................................... 7
PARTNER ....................................... 8
ROOMMATE ................................... 9
OTHER RELATIVE.......................... 10
OTHER NON-RELATIVE ................ 11
REFUSED ................................... 9--97
DON’T KNOW ............................. 9--98
YES .................................. 1
NO .................................... 2
REFUSED .................... 9--97
DON’T KNOW .............. 9--98
Appendix A
A.1.1.a–8
Appendix A
A.1.1.a–9
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
BOX EN04
PROGRAMMER INSTRUCTION:
IF ANY WOMEN <18 OR >49 YEARS LIVING IN HOUSEHOLD (EN019 < 18 OR >
49) AND NOT PREGNANT (EN021 NE “1” FOR THE SAME WOMAN), DISPLAY THE
FOLLOWING ERROR MESSAGE: “Women who are <18 or >49 years old should not
be entered on the grid unless they are pregnant. Please back up and confirm age and
pregnancy status. Delete name for any non-eligible women.”
EN022. I have recorded that there {is one woman living here who is between 18 and 49 /are {NUMBER} women living
here who are between 18 and 49: (READ NAME(S) BELOW) {and yourself}}. This number should include all
women 18 to 49 who usually live here, even those who may be temporarily away, such as away on business, on
vacation, on active military duty, in a hospital, or in school. Is this correct?
YES, ALL WOMEN INCLUDED ............................................................... 1
NO, THE NUMBER OF WOMEN IS INCORRECT................................... 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX EN05
PROGRAMMER INSTRUCTION:
IF INCORRECT NUMBER (EN022 = “2”), DISPLAY THE FOLLOWING
MESSAGE: “The R has indicated that the enumeration grid is not correct. The
computer will return to the grid to allow you to change the names, ages,
relationships and pregnancy status.”
BOX EN06
CHECK ITEM:
IF INCORRECT NUMBER (EN022 = “2”), AFTER INTERVIEWER CLEARS THE
MESSAGE, GO TO EN023. ALLOW INTERVIEWER TO EDIT AND/OR ADD
RECORDS TO HH WOMEN ENUMERATION GRID (EN023–EN026).
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
HH WOMENENUMERATION GRID—QUESTIONS EN023–EN026
EN023. NAME: What is (her/your/the next woman’s) first name?
EN024. AGE: How old (is she/are you)?
EN025. RELATIONSHIP: How is she related to you?
EN026. PREGNANT: Since this is a study of children’s health, it is important to identify pregnant women. (Is she/Are you) pregnant?
INTERVIEWER INSTRUCTION:
NAME: COLLECT UNIQUE NAME.
RELATIONSHIP: IF R IS BEING ENUMERATED, SELECT “SELF” WITHOUT ASKING.
PREGNANT: COLLECT PREGNANCY STATUS. CONFIRM IF PREVIOUSLY REPORTED.
EN023. NAME
EN024. AGE
EN025. RELATIONSHIP
EN026. PREGNANT
__________________
UNIQUE FIRST NAME
|__|__|
AGE
REFUSED ........................... 9--97
DON’T KNOW...................... 9--98
REFUSED ............................ 9--97
DON’T KNOW ...................... 9--98
SELF ............................................... 1
WIFE ............................................... 2
DAUGHTER .................................... 3
GRANDDAUGHTER ....................... 4
MOTHER......................................... 5
GRANDMOTHER ............................ 6
SISTER ........................................... 7
PARTNER ....................................... 8
ROOMMATE ................................... 9
OTHER RELATIVE.......................... 10
OTHER NON-RELATIVE ................ 11
REFUSED ................................... 9--97
DON’T KNOW ............................. 9--98
YES .................................. 1
NO .................................... 2
REFUSED .................... 9--97
DON’T KNOW .............. 9--98
Appendix A
A.1.1.a–10
Appendix A
A.1.1.a–11
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
BOX EN07
PROGRAMMER INSTRUCTION:
IF ANY WOMEN <18 OR >49 YEARS LIVING IN HOUSEHOLD (EN024 < 18 OR >
49) AND NOT PREGNANT (EN026 NE “1”) FOR THE SAME WOMAN), DISPLAY
THE FOLLOWING ERROR MESSAGE: “Women who are <18 or >49 years old should
not be entered on the grid unless they are pregnant. Please back up and confirm age
and pregnancy status. Delete name for any non-eligible women.”
EN027. We’ve just been talking about the women in your household who are 18 {to 49/or older}. Now I want you to think
about all of the females living in this household. {You’ve already told me {READ NAMES BELOW} {is/are}
pregnant/ you are pregnant}. Are there any females in this household who are pregnant {that we have not already
talked about}?
ADDITIONAL PREGNANT FEMALES IN HOUSEHOLD ......................... 1
NO ADDITIONAL PREGNANT FEMALES IN HOUSEHOLD................... 2
NO FEMALES OF ANY AGE IN HOUSEHOLD ....................................... 3
RECORD OF PREGNANT FEMALE(S) IN GRID IS INACCURATE........ 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX EN08
PROGRAMMER INSTRUCTION:
IF YES, THERE ARE ADDITIONAL PREGNANT FEMALES (EN027 = “1”),
DISPLAY THE FOLLOWING MESSAGE: “The R has indicated that there is at
least one additional eligible woman living in the household. The computer will
return to the enumeration grid to allow you to add the additional pregnant
female(s).”
IF RECORD OF PREGNANT FEMALES IN GRID INACCURATE (EN027 = “4”),
DISPLAY THE FOLLOWING MESSAGE: “The R has indicated that the pregnancy
status is not accurate for at least one of the females in the grid. The computer will
return to the enumeration grid to allow you to correct this.”
BOX EN09
CHECK ITEM:
IF THERE WERE ADDITIONAL WOMEN (EN027 = “1”) OR RECORD OF
PREGNANT FEMALES IS INACCURATE FOR AT LEAST ONE RECORD
(EN027 = “4”), AFTER INTERVIEWER CLEARS THE MESSAGE, GO TO EN028.
ALLOW INTERVIEWER TO ADD OR CHANGE RECORDS IN HH WOMEN
ENUMERATION GRID (EN028–EN031).
OTHERWISE, GO TO EN032.
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
HH WOMEN ENUMERATION GRID—QUESTIONS EN028–EN031
EN028. NAME: What is (her/your/the next woman’s) first name?
EN029. AGE: How old (is she/are you)?
EN030. RELATIONSHIP: How is she related to you?
EN031. PREGNANT: Since this is a study of children’s health, it is important to identify pregnant women. (Is she/Are you) pregnant?
INTERVIEWER INSTRUCTION:
NAME: COLLECT UNIQUE NAME.
RELATIONSHIP: IF R IS BEING ENUMERATED, SELECT “SELF” WITHOUT ASKING.
PREGNANT: COLLECT PREGNANCY STATUS. CONFIRM IF PREVIOUSLY REPORTED.
EN028. NAME
EN029. AGE
EN030. RELATIONSHIP
EN031. PREGNANT
__________________
UNIQUE FIRST NAME
|__|__|
AGE
REFUSED ........................... 9—97
DON’T KNOW...................... 9--98
REFUSED ............................ 9--97
DON’T KNOW ...................... 9--98
SELF ............................................... 1
WIFE ............................................... 2
DAUGHTER .................................... 3
GRANDDAUGHTER ....................... 4
MOTHER......................................... 5
GRANDMOTHER ............................ 6
SISTER ........................................... 7
PARTNER ....................................... 8
ROOMMATE ................................... 9
OTHER RELATIVE.......................... 10
OTHER NON-RELATIVE ................ 11
REFUSED ................................... 9--97
DON’T KNOW ............................. 9--98
YES .................................. 1
NO .................................... 2
REFUSED .................... 9--97
DON’T KNOW .............. 9--98
Appendix A
A.1.1.a–12
Appendix A
A.1.1.a–13
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
BOX EN10
PROGRAMMER INSTRUCTION:
IF ANY WOMEN <18 OR >49 YEARS LIVING IN HOUSEHOLD (EN029 < 18 OR >
49) AND NOT PREGNANT (EN031 NE “1” FOR THE SAME WOMAN), DISPLAY THE
FOLLOWING ERROR MESSAGE: “Women who are <18 or >49 years old should not
be entered on the grid unless they are pregnant. Please back up and confirm age and
pregnancy status. Delete name for any non-eligible women.”
EN032. INTERVIEWER INSTRUCTION:
SELECT BELOW BY OBSERVATION. IF UNSURE SELECT SINGLE-FAMILY HOME.
SINGLE-FAMILY HOME .......................................................................... 1
GROUP QUARTERS ............................................................................... 2
MULTI UNIT ............................................................................................. 3 (EN035)
REFUSED .......................................................................................... 9--97 (EN036)
DON’T KNOW .................................................................................... 9--98 (EN036)
EN033. I want to be sure that every household in this area has been given a chance to participate in this important study.
Are there any other living quarters here such as a basement apartment?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EN036)
REFUSED .......................................................................................... 9--97 (EN036)
DON’T KNOW .................................................................................... 9--98 (EN036)
EN034. Where is this unit located?
INTERVIEWER INSTRUCTION:
CONFIRM IF KNOWN. RECORD UNIT ADDRESS OR LOCATION/DESCRIPTION ON LISTING NOTES FORM.
CONFIRM UNIT IS NOT ALREADY LISTED AFTER COMPLETING THE ENUMERATION.
LOCATION ENTERED ON LISTING NOTES FORM............................... 1 (EN036)
REFUSED .......................................................................................... 9--97 (EN036)
DON’T KNOW .................................................................................... 9--98 (EN036)
EN035. INTERVIEWER INSTRUCTION:
IS THIS THE FIRST UNIT IN BUILDING?
YES (COME BACK TO HIDDEN DU PROCEDURE)...............................
NO (HIDDEN DU PROCEDURE NOT REQUIRED) ................................
1
2
Appendix A
A.1.1.a–14
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
EN036. I have a few more questions for you so that my supervisor can check my work. What is your first and last name?
INTERVIEWER INSTRUCTION:
CONFIRM FIRST NAME IF KNOWN.
_________________________
FIRST NAME
_________________________
LAST NAME
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
EN037. And what’s the best phone number to reach you?
|__|__|__| |__|__|__| -- |__|__|__|__|
PHONE NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (BOX EN11)
9--98 (BOX EN11)
EN038. Is this your home, work, cell, or another phone number?
INTERVIEWER INSTRUCTION:
CONFIRM IF KNOWN.
HOME....................................................................................................... 1
WORK ...................................................................................................... 2
CELL ........................................................................................................ 3
FRIEND/RELATIVE (SPECIFY): _______________________________ 4
OTHER (SPECIFY): _________________________________________ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX EN11
CHECK ITEM:
IF GROUP LIVING QUARTERS (EN004 = “2”), GO TO BOX EN12.
IF PRIVATE RESIDENCE (EN004 = ”1”) AND R PROVIDED HOME PHONE
NUMBER (EN038 = “1”), GO TO EN040.
OTHERWISE, GO TO EN039.
Appendix A
A.1.1.a–15
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
EN039. What is your home telephone number?
|__|__|__| |__|__|__| -- |__|__|__|__|
PHONE NUMBER
NONE/NO LAND LINE .......................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--90
9--97
9--98
EN040. For my records, I just have a few more questions. Are you Hispanic or (Latino/Latina)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EN041. And, please tell me which of the following categories describes your race. You may select more than one.
INTERVIEWER INSTRUCTION:
SELECT ALL THAT APPLY.
White ........................................................................................................ 1
Black or African American ........................................................................ 2
Asian ........................................................................................................ 3
Native Hawaiian or Other Pacific Islander ................................................ 4
American Indian or Alaska Native ............................................................ 5
Some other race (SPECIFY): __________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX EN12
CHECK ITEM:
IF R IS ELIGIBLE WOMAN AND THERE ARE NO PREGNANT WOMEN UNDER
18 IN HOUSEHOLD, GO TO ENCLOSE2.
IF R IS NOT ELIGIBLE WOMAN AND THERE ARE NO PREGNANT WOMEN
UNDER 18 IN HOUSEHOLD, GO TO ENCLOSE3.
IF R IS AN ELIGIBLE WOMAN AND THERE IS AT LEAST 1 PREGNANT
WOMAN UNDER 18 IN HOUSEHOLD, GO TO ENCLOSE4.
IF R IS NOT AN ELIGIBLE WOMAN AND THERE IS AT LEAST 1 PREGNANT
WOMAN UNDER 18 IN HOUSEHOLD, GO TO ENCLOSE5.
OTHERWISE, IF NO ELIGIBLE WOMEN IN HOUSEHOLD, GO TO ENCLOSE1.
Appendix A
A.1.1.a–16
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
ENCLOSE1. Thank you for your time. At this point, it looks like no one in this household is eligible for this study. We will
check back with you again in a few years to see if this has changed.
BOX EN13
GO TO EN_END.
ENCLOSE2. Thank you for your time. Based on our conversation I need to ask {(READ NAMES BELOW) and} you} a few
more questions. This should only take about 5 minutes.
The National Children’s Study is asking women questions to get information about pregnancy and to find out
who is eligible to be in the Study. Answering the questions does not mean that you agree to be in the Study.
Only a small number of women who answer these questions will be eligible to be in the Study. If you are in
one of the groups needed for the Study, we will give you more information so you can decide if you want to
be in the Study. If you are not in one of the groups needed for the Study at this time, we may use the
answers you give us, and we may call you back at a later date to see if anything has changed.
{Some people may consider questions about pregnancy to be personal, so we will give you choices on how
you would like to listen to the questions. You can listen to the questions privately using headphones, or you
can listen without headphones, or I can read the questions to you. You will enter your answers directly into
the computer without telling me your answers. The computer will determine if you are eligible for 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.}
INTERVIEWER INSTRUCTION:
LAUNCH AND BEGIN PREGNANCY SCREENER WITH R.
IF R IS NOT AVAILABLE OR PREGNANCY SCREENER IS FINISHED, DETERMINE IF ANY
ADDITIONAL ELIGIBLE WOMEN ARE ABLE TO COMPLETE PREGNANCY SCREENER.
IF UNCOMPLETED PREGNANCY SCREENERS, DETERMINE TIME TO RETURN WHEN
ELIGIBLE WOMEN AVAILABLE, LAST NAME(S) AND BEST TELEPHONE NUMBER(S) AND
ENTER INTO PREGNANCY SCREENER EROC.
THANK R, GIVE COPY OF STUDY BROCHURE, AND LEAVE HOUSEHOLD.
BOX EN14
GO TO EN_END
ENCLOSE3. Thank you for your time. Based on our conversation I need to ask {READ NAMES BELOW} a few questions.
This will take about 5 minutes. {Is she/Are either of them/Are any of them} available?
INTERVIEWER INSTRUCTION:
IF ELIGIBLE WOMAN AVAILABLE AGE 18 OR OLDER, LAUNCH AND BEGIN PREGNANCY
SCREENER.
IF ELIGIBLE WOMAN IS NOT AVAILABLE, DETERMINE IF ADDITIONAL ELIGIBLE WOMEN ARE
ABLE TO COMPLETE PREGNANCY SCREENER.
IF INCOMPLETE PREGNANCY SCREENERS, DETERMINE TIME TO RETURN WHEN ELIGIBLE
WOMEN AVAILABLE, LAST NAME(S) AND BEST TELEPHONE NUMBER(S) AND ENTER INTO
PREGNANCY SCREENER EROC.
THANK R, GIVE COPY OF STUDY BROCHURE, AND LEAVE HOUSEHOLD.
Appendix A
A.1.1.a–17
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
BOX EN15
GO TO EN_END
ENCLOSE4. Thank you for your time. Based on our conversation, here’s what I need to do next. First, I need to ask you a
few more questions. Then, since (READ NAMES OF UNDER 18 ELIGIBLE FEMALE(S) BELOW) {is/are}
under 18, I will also need to speak with {her/their} parent or legal guardian. {After that, I will need to speak
with (READ NAMES OF ELIGIBLE WOMEN 18 AND OLDER BELOW).}
Let’s start with you. This should take about 5 minutes. The National Children’s Study is asking women
questions to get information about pregnancy and to find out who is eligible to be in the Study. Answering
the questions does not mean that you agree to be in the Study. Only a small number of women who answer
these questions will be eligible to be in the Study. If you are in one of the groups needed for the Study, we
will give you more information so you can decide if you want to be in the Study. If you are not in one of the
groups needed for the Study at this time, we may use the answers you give us, and we may call you back at
a later date to see if anything has changed.
{Some people may consider questions about pregnancy to be personal, so we will give you choices on how
you would like to listen to the questions. You can listen to the questions privately using headphones, or you
can listen without headphones, or I can read the questions to you. You will enter your answers directly into
the computer without telling me your answers. The computer will determine if you are eligible for the Study.
It would be best if you could sit down in a chair or at a table for this. Please let me know where a
comfortable spot would be to get you set up.}
INTERVIEWER INSTRUCTION:
LAUNCH AND BEGIN PREGNANCY SCREENER WITH R.
WHEN COMPLETE OR IF R NOT AVAILABLE, ASK TO SPEAK WITH PARENT OR LEGAL
GUARDIAN OF ELIGIBLE FEMALE UNDER 18 AND LAUNCH PREGNANCY SCREENER WITH
PARENT AS PROXY.
IF PARENT OR LEGAL GUARDIAN OF ELIGIBLE FEMALE UNDER 18 IS NOT AVAILABLE OR IF
PREGNANCY SCREENER COMPLETE, DETERMINE IF ANY ADDITIONAL ELIGIBLE WOMEN
ARE ABLE TO COMPLETE PREGNANCY SCREENER.
IF INCOMPLETE PREGNANCY SCREENERS, DETERMINE TIME TO RETURN WHEN ELIGIBLE
WOMEN AVAILABLE, LAST NAME(S) AND BEST TELEPHONE NUMBER(S) AND ENTER INTO
PREGNANCY SCREENER EROC.
THANK R, GIVE COPY OF STUDY BROCHURE, AND LEAVE HOUSEHOLD.
BOX EN16
GO TO EN_END
Appendix A
A.1.1.a–18
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
ENCLOSE5. Thank you for your time. Based on our conversation, I will first need to speak with the parent or guardian of
{READ NAMES OF UNDER 18 ELIGIBLE FEMALE(S) BELOW}. {I then need to ask {READ NAMES OF
ELIGIBLE WOMEN 18 AND OLDER BELOW } a few questions.} {Is her parent or legal guardian available/Is
one of their parents or a legal guardian available/Is the parent or guardian of {READ NAMES OF UNDER 18
ELIGIBLE FEMALE(S) BELOW} available}? This will take about 5 minutes.
INTERVIEWER INSTRUCTION:
LAUNCH AND BEGIN PREGNANCY SCREENER WITH PARENT OR LEGAL GUARDIAN OF
ELIGIBLE FEMALE UNDER 18.
IF PARENT OR LEGAL GUARDIAN OF ELIGIBLE FEMALE UNDER 18 IS NOT AVAILABLE OR
PREGNANCY SCREENER COMPLETE, DETERMINE IF ADDITIONAL ELIGIBLE WOMEN ARE
ABLE TO COMPLETE PREGNANCY SCREENER.
IF INCOMPLETE PREGNANCY SCREENERS, DETERMINE TIME TO RETURN WHEN ELIGIBLE
WOMEN AVAILABLE, LAST NAME(S) AND BEST TELEPHONE NUMBER(S) AND ENTER INTO
PREGNANCY SCREENER EROC.
THANK R, GIVE COPY OF STUDY BROCHURE, AND LEAVE HOUSEHOLD.
BOX EN17
GO TO EN_END
ENCLOSE6. Thank you for your time.
INTERVIEWER INSTRUCTION:
ENTER IN EROC AND NIRF.
BOX EN18
GO TO EN_END
ENCLOSE7. Thank you for your time. When would be a good time to come back to speak with the (manager or
administrator)?
INTERVIEWER INSTRUCTION:
RECORD TIME AND DAYS MANAGER OR ADMINISTRATOR AVAILABLE
ENTER IN EROC
BOX EN19
GO TO EN_END
ENCLOSE8. Thank you for your time. At this point, it looks like no one in this household is eligible for this study.
Appendix A
A.1.1.a–19
Version 1/20/08
Visit Type: Enumeration
Target: Adult Household Member
EN_END
SET ENUMERATION COMPONENT STATUS.
END ENUMERATION.
Appendix A
A.1.1.b–1
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
PREGNANCY SCREENER (AUDIO CASI) VISIT: SECTION PS
Start Module 1, Section 1
PS001. INTERVIEWER INSTRUCTION:
IS INTERVIEW TO BE CONDUCTED IN PERSON OR VIA PHONE?
IN PERSON..............................................................................................
PHONE.....................................................................................................
1
2
PS002. INTERVIEWER INSTRUCTION:
ARE YOU CONTINUING THE PREGNANCY SCREENER ON THE SAME DAY AND WITH THE SAME
PERSON WHO COMPLETED THE ENUMERATION?
YES ..........................................................................................................
NO ............................................................................................................
1
2
BOX PS01
CHECK ITEM:
IF THIS IS NOT A PROXY INTERVIEW AND ENUMERATION ADMINISTERED
TO CURRENT RESPONDENT, GO TO BOX PS05.
IF THIS IS A PROXY INTERVIEW WITH THE PARENT OR LEGAL GUARDIAN
OF AN ELIGIBLE FEMALE UNDER 18 AND THE PREGNANCY SCREENER IS
NOT BEING ADMINISTERED ON THE SAME DAY AS THE ENUMERATION
WITH THE SAME RESPONDENT (PS002 = ”2”), CONTINUE WITH PS003.
IF THIS IS A PROXY INTERVIEW WITH THE PARENT OR LEGAL GUARDIAN
OF AN ELIGIBLE FEMALE UNDER 18 AND THE PREGNANCY SCREENER IS
BEING ADMINISTERED AT THE SAME VISIT AS THE ENUMERATION WITH
THE SAME RESPONDENT (PS002 = ”1”), GO TO BOX PS05.
OTHERWISE, CONTINUE WITH PS003.
PS003. OK, {{READ NAME BELOW}}, I’ll begin by confirming some information I have for {(NAME)/you}. How old {are
you/is {NAME}}?
INTERVIEWER INSTRUCTION:
IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.
|___|___|
AGE
WRONG CASE ........................................................................................ 990 (PSCLSE1)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
Appendix A
A.1.1.b–2
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
BOX PS02
CHECK ITEM:
IF THIS IS A PROXY INTERVIEW, GO TO BOX PS05.
OTHERWISE, CONTINUE WITH BOX PS03.
BOX PS03
CHECK ITEM:
IF AGE CONFIRMS ELIGIBILITY (PS003 >=18 AND < 50), CONTINUE WITH
PS004.
IF AGE 50 OR OLDER AND REPORTED PREGNANT IN ENUMERATION,
CONTINUE WITH PS004.
IF AGE LESS THAN 18 AND REPORTED PREGNANT IN ENUMERATION, GO
TO PSCLSE2.
IF AGE LESS THAN 18 AND NOT REPORTED PREGNANT IN ENUMERATION,
GO TO PSCLSE3.
OTHERWISE, IF AGE 50 OR OLDER AND NOT PREGNANT ON
ENUMERATION, GO TO PSCLSE3.
PS004. What is your address?
STREETNO: {StreetNo} PREDIR: {PreDir} STREET: {Street} STYPEID: {StTypeID} POSTDIR: {PostDir}
UNITYPEID: {UnitTypeID} UNITNO: {UnitNo}
CITY: {City}
STATE: {State}
ZIP CODE: {Zip} ZIPPLUS4: {ZipPlus4}
YES, CORRECT ADDRESS .................................................................... 1
YES (BUT WITH MINOR CORRECTIONS) ............................................. 2
NO (WRONG ADDRESS) ........................................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(BOX PS05)
(PS006)
(PSCLSE1)
(EOS)
(EOS)
PS006. INTERVIEWER INSTRUCTION:
CONFIRM CORRECTIONS WITH RESPONDENT.
STREETNO: {StreetNo} PREDIR: {PreDir} STREET: {Street} STYPEID: {StTypeID} POSTDIR: {PostDir}
UNITYPEID: {UnitTypeID} UNITNO: {UnitNo}
CITY: {City}
STATE: {State}
ZIP CODE: {Zip} ZIPPLUS4: {ZipPlus4}
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.1.b–3
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
BOX PS05
CHECK ITEM:
IF THIS IS A PROXY INTERVIEW CONDUCTED WITH THE PARENT OR
LEGAL GUARDIAN OF AN ELIGIBLE FEMALE UNDER 18, CONTINUE WITH
PS007.
IF NOT A PROXY INTERVIEW AND R SAME RESPONDENT AS
ENUMERATION AND SHE REPORTED HERSELF PREGNANT IN
ENUMERATION, CONTINUE WITH PS007.
IF NOT A PROXY INTERVIEW AND R SAME RESPONDENT AS
ENUMERATION AND SHE REPORTED HERSELF AS NOT PREGNANT IN
ENUMERATION, GO TO PS013.
OTHERWISE, GO TO PS012.
PS007. {You told me earlier that you are/As we discussed earlier, {NAME} is} pregnant. When is the baby due?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
NO LONGER PREGNANT .................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--90
9--97
9--98
BOX PS06
CHECK ITEM:
IF PROXY INTERVIEW WITH PARENT/LEGAL GUARDIAN AND ANSWERED
REFUSED OR DON’T KNOW TO BABY’S DUE DATE, GO TO PS009.
IF NO LONGER PREGNANT, GO TO EOS.
IF VALID DATE ENTERED IN PS007, GO TO EOS.
OTHERWISE, CONTINUE WITH PS008.
PS008. What was the first day of your last menstrual period?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
BOX PS07
GO TO EOS.
9--97 (PS009)
9--98 (PS009)
Appendix A
A.1.1.b–4
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
PS009. About how many weeks pregnant {are you/is {NAME}}? If you’re not sure, please make your best guess.
|___|___|
NUMBER OF WEEKS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (PS010)
9--98 (PS010)
BOX PS08
GO TO EOS.
PS010. About how many months pregnant {are you/is {NAME}}? If you’re not sure, please make your best guess.
|___|___|
NUMBER OF MONTHS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (PS011)
9--98 (PS011)
BOX PS09
GO TO EOS.
PS011. {Are you/Is {NAME}} currently in {your/her} 1st, 2nd, or 3rd trimester?
1ST Trimester (1 to 3 months pregnant) ....................................................
2ND Trimester (4 to 6 months pregnant)....................................................
3RD Trimester (7 to 9 months pregnant)....................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
BOX PS10
GO TO EOS.
1
2
3
9--97 (EOS)
9--98 (EOS)
Appendix A
A.1.1.b–5
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
PS012. Now, I have a few questions for you to answer on your own to determine if you might be eligible for the National
Children’s Study. This should take about 5 minutes.
The National Children’s Study is asking women questions to get information about pregnancy and to find out who
is eligible to be in the Study. Answering the questions does not mean that you agree to be in the Study. Only a
small number of women who answer these questions will be eligible to be in the Study. If you are in one of the
groups needed for the Study, we will give you more information so you can decide if you want to be in the Study.
If you are not in one of the groups needed for the Study at this time, we may use the answers you give us, and we
may call you back at a later date to see if anything has changed.
Some people may consider questions about pregnancy to be personal, so we will give you choices on how you
would like to listen to the questions. You can listen to the questions privately using headphones, or you can listen
without headphones, or I can read the questions to you. You will enter your answers directly into the computer
without telling me your answers. The computer will determine if you are eligible for 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.
PS013. OK, I’d now like to give you some important information. Answering these questions is your choice. You do not
have to answer these questions, you can stop the interview at any time, and there will be no penalties or loss of
any benefits you may be getting. But please keep in mind that your answers to these questions are very
important. The information we collect is protected by law and we will keep all the information private. This Study
has a legal document called a Certificate of Confidentiality that will protect your information from people who are
not part of the Study. With this document, we cannot be forced, even by the courts, to tell anyone who is not
connected to the Study about your participation or your personal information without written permission from you.
PS014. As I said earlier, some of these questions may be somewhat sensitive. You can choose how you would like to
answer these questions. Would you like to
Listen to the questions on your own using headphones, ..........................
Listen to the questions on your own without headphones, or..................
Have me read the questions to you?........................................................
1
2
3
INTERVIEWER INSTRUCTIONS:
IF R WILL LISTEN TO QUESTIONS ON HER OWN (EITHER WITH OR WITHOUT HEADPHONES) THEN:
SET UP R SO THAT SHE IS SITTING DOWN IN FRONT OF THE COMPUTER SCREEN.
TURN SCREEN TOWARDS R AND ASSIST R WITH PRACTICE QUESTIONS.
PS015. The National Children’s Study is enrolling women of child-bearing age to get information about pregnancy. These
questions will help us to see if you can take part in the Study. Answering them does not mean that you agree to
be part of the Study.
BOX PS11
GO TO EOS.
Appendix A
A.1.1.b–6
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
PSCLSE1. It looks like I may have selected the wrong case. It will take just a moment while I check in the computer.
INTERVIEWER INSTRUCTIONS:
EXIT THE PREGNANCY SCREENER AND SELECT THE CORRECT CASE AND/OR ADDRESS FROM
YOUR ASSIGNMENT LIST.
BOX PS12
GO TO EOS.
PSCLSE2. Thank you. Since you are under 18, I must speak with one of your parents or a legal guardian. Is one of your
parents or a legal guardian available to talk right now?
BOX PS13
GO TO EOS.
PSCLSE3. Thank you for answering these questions. Based on the information you’ve provided, you are not eligible for
this study at this time.
INTERVIEWER INSTRUCTIONS:
WHEN FINISHED, INQUIRE WHETHER ANY ADDITIONAL ELIGIBLE FEMALES ARE AVAILABLE.
EOS
START OF AUDIO CASI
Start Module 2, Section 1
BOX PS15
PROGRAMMER INSTRUCTIONS:
IF WOMAN NO LONGER PREGNANT, CASE IS NOT ELIGIBLE FOR MODULE
2. GO TO MODULE 3.
IF SPEAKING WITH PARENT OR LEGAL GUARDIAN, CASE IS NOT ELIGIBLE
FOR MODULE 2. GO TO MODULE 3.
IF R SAME RESPONDENT AS ENUMERATION AND SHE REPORTED
HERSELF PREGNANT IN THE ENUMERATION, CASE IS NOT ELIGIBLE FOR
MODULE 2. GO TO MODULE 3.
IF MODULE 1, SECTION 1 STATUS = “PARTIAL” OR “NOT DONE”, CASE IS
NOT ELIGIBLE FOR MODULE 2. GO TO MODULE 3.
IF INTERVIEWER WILL READ ACASI QUESTIONS TO RESPONDENT, CASE
IS NOT ELIGIBLE FOR MODULE 2, SECTION 1. GO TO MODULE 2, SECTION
2.
OTHERWISE, CASE IS ELIGIBLE FOR MODULE 2.
Appendix A
A.1.1.b–7
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
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.
PS017. What is your favorite soft drink?
RESPONDENT INSTRUCTION:
“Use the stylus to select your answer. Press ‘NEXT’ when you are done.”
Coke .........................................................................................................
Pepsi ........................................................................................................
Sprite ........................................................................................................
7-Up .........................................................................................................
Another soft drink .....................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
5
9--97
9--98
PS018. During a typical week, how many movies do you watch?
RESPONDENT INSTRUCTION:
“Use the keypad to enter the number and press ‘NEXT’ when you are done.”
|___|___|
NUMBER OF MOVIES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
PS019. What is today’s date?
RESPONDENT INSTRUCTION:
“Use the keypad to enter today’s date, starting with the 2-digit month, next the 2-digit day, and lastly the 4-digit
year. Press ‘NEXT’ when you are done.”
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
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.
{Please put on the headphones now.} Your interviewer will help you adjust the volume. When you are ready,
press “NEXT” to see the first question.
INTERVIEWER INSTRUCTION:
GIVE RESPONDENT HEAD PHONES AND ADJUST VOLUME.
Appendix A
A.1.1.b–8
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
EOS
END MODULE 2, SECTION 1.
Start Module 2, Section 2
BOX PS16
CHECK ITEM:
IF PREGNANCY SCREENER ADMINISTERED ON SAME DAY AND WITH THE
SAME PERSON WHO COMPLETED THE ENUMERATION, GO TO BOX PS17.
OTHERWISE, CONTINUE WITH PS021.
PS021. Are you pregnant now?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
BOX PS17
CHECK ITEM:
IF R LAST REPORTED PREGNANT IN PREGNANCY SCREENER, GO TO
PS023.
IF R LAST REPORTED PREGNANT IN ENUMERATION AND PS021 IS NOT
ASKED, GO TO PS023.
IF R LAST REPORTED NOT PREGNANT IN THE PREGNANCY SCREENER,
GO TO PS028.
IF R LAST REPORTED NOT PREGNANT IN THE ENUMERATION, AND PS021
IS NOT ASKED, GO TO PS028.
IF R LAST REPORTED SHE DOESN’T KNOW IF PREGNANT OR REFUSED TO
ANSWER IN THE PREGNANCY SCREENER, CONTINUE WITH PS022.
OTHERWISE, IF R LAST REPORTED SHE DOESN’T KNOW IF PREGNANT OR
REFUSED TO ANSWER IN THE ENUMERATION, AND PS021 IS NOT ASKED,
CONTINUE WITH PS022.
PS022. Do you think you are probably pregnant or not?
Yes, probably pregnant ............................................................................
No, probably not pregnant ........................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (PS028)
9--97 (PS028)
9--98 (PS028)
Appendix A
A.1.1.b–9
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
PS023. When is your baby due?
RESPONDENT INSTRUCTION:
“Use the keypad to enter your baby’s due date, starting with the 2-digit month, next the 2-digit day, and lastly the
4-digit year. Press ‘NEXT’ when you are done.”
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX PS18
CHECK ITEM:
IF PS023 = “9--97” OR “9--98”, CONTINUE WITH PS024.
OTHERWISE, GO TO PS035.
PS024. What was the first day of your last menstrual period?
RESPONDENT INSTRUCTION:
“Using the keypad, enter the 2-digit 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
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (PS025)
9--98 (PS025)
BOX PS19
GO TO PS035.
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.
|___|___|
NUMBER OF WEEKS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
BOX PS20
GO TO PS035.
9--97 (PS026)
9--98 (PS026)
Appendix A
A.1.1.b–10
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
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.
|___|___|
NUMBER OF MONTHS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (PS027)
9--98 (PS027)
BOX PS21
GO TO PS035.
PS027. Are you currently in your 1st, 2nd, or 3rd trimester?
1ST Trimester (1 to 3 months pregnant) ....................................................
2ND Trimester (4 to 6 months pregnant)....................................................
3RD Trimester (7 to 9 months pregnant)....................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
9--97 (PS035)
9--98 (PS035)
BOX PS22
GO TO 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?
RESPONDENT INSTRUCTION:
Enter the number of months using the keypad. If you have been trying for less than one month, enter 0.
|___|___|
NUMBER OF MONTHS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.1.b–11
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
BOX PS23
GO TO PS035.
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 ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1 (PS035)
2
9--97
9--98
BOX PS24
IF RESPONDENT IS AGE 45–49 AND R IS THE ENUMERATION R AND THIS
IS NOT A PROXY INTERVIEW, GO TO PS035.
OTHERWISE, CONTINUE WITH PS031.
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 ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (PS035)
9--97 (PS035)
9--98 (PS035)
PS032. Has your current sexual partner had a vasectomy?
Yes ...........................................................................................................
No.............................................................................................................
Not sure....................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1 (PS035)
2
3
9--97
9--98
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 contraception or do anything to prevent pregnancy?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (PS035)
9--97 (PS035)
9--98 (PS035)
Appendix A
A.1.1.b–12
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
PS034. What did you use? You may select more than one answer. Did you use birth control pills; use a condom; use
Depo-Provera or other shots or injections; use natural family planning, including rhythm or safe period by
calendar, temperature, or cervical mucus; use a diaphragm, cervical cap, or shield; use foam, jelly, cream, a
suppository, or other insert; use a female condom or vaginal pouch; use the patch, Norplant, the ring, or Nuva
ring; use a TODAY sponge; use an IUD, coil, or loop; use Plan B or the “Morning After” pill; use withdrawal or
“pulling out”; or did you use some other method or do something else?
RESPONDENT INSTRUCTION:
If you make a mistake, press the “CLEAR” button to re-enter your answer. Press the “NEXT” button when you
have finished answering the question.
Birth control pills ....................................................................................... 1
Condoms .................................................................................................. 2
Depo-Provera/shots/injections.................................................................. 3
Natural family planning ............................................................................. 4
Diaphragm/cap/shield............................................................................... 5
Foam/jelly/cream/insert ............................................................................ 6
Female condom/vaginal pouch................................................................. 7
Patch/Norplant/Nuva ring ......................................................................... 8
TODAY sponge ........................................................................................ 9
IUD/Coil/Loop ........................................................................................... 10
Plan B/“Morning After” pill......................................................................... 11
Withdrawal/pulling out ............................................................................. 12
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.}
BOX PS25
IF R COMPLETED ACASI ON HER OWN, CONTINUE WITH PS036.
OTHERWISE, GO TO EOS.
PS036. INTERVIEWER INSTRUCTIONS:
REARRANGE COMPUTER FOR INTERVIEWER USE.
PUT AWAY EARPHONES AND DISPOSE OF EARPHONE COVERS.
TURN OFF VOLUME.
SELECT “NEXT” TO CONTINUE. THE COMPUTER WILL RUN THE ALGORITHM AND ASSIGN THE
WOMAN TO A GROUP.
EOS
END MODULE 2, SECTION 2.
END OF AUDIO CASI
Appendix A
A.1.1.b–13
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
BOX PS27
RUN ALGORITHM AND ASSIGN PROBABILITY OF PREGNANCY GROUP
(PPG).
Start Module 3, Section 1
BOX PS28
CHECK ITEM:
IF MODULE 1, SECTION 1 STATUS IS “NOT DONE” OR “PARTIAL,” CASE IS
NOT ELIGIBLE FOR MODULE 3, GO TO MODULE 4.
OTHERWISE, CONTINUE WITH BOX PS29.
BOX PS29
CHECK ITEM:
IF IN NO FOLLOW UP GROUP AND REPORTED <18 YEARS OLD AND
PREGNANT IN ENUMERATION AND STILL PREGNANT AT PREGNANCY
SCREENER, GO TO PS042.
IF IN PREGNANT ELIGIBLE GROUP AND <18 YEARS OLD, GO TO PS042.
IF IN HOLDING GROUP AND NO LONGER PREGNANT, GO TO PS042.
IF IN NO FOLLOW UP GROUP AND NO LONGER PREGNANT, GO TO
PSCLSE10.
OTHERWISE, CONTINUE WITH BOX PS29A.
BOX PS29A
CHECK ITEM:
IF PREGNANCY SCREENER WAS PREVIOUSLY LAUNCHED AND MODULE 4
STATUS IS “COMPLETE,” GO TO PS042.
OTHERWISE, CONTINUE WITH PS037.
PS037. The computer will now process your answers. While we wait, I’ll ask you some questions about how you heard of
our study.
PS038. Before today, had you heard about the National Children’s Study?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PS042)
REFUSED .......................................................................................... 9--97 (PS042)
DON’T KNOW .................................................................................... 9--98 (PS042)
Appendix A
A.1.1.b–14
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
PS039. How did you hear about the National Children’s Study?
INTERVIEWER INSTRUCTION:
SELECT ALL THAT APPLY.
FRIENDS OR ACQUAINTANCES ........................................................... 1
FAMILY MEMBERS ................................................................................. 2
CHURCH, SYNAGOGUE, OR OTHER RELIGIOUS AFFILIATION......... 3
A COMMUNITY LEADER......................................................................... 4
SOMEONE ELSE IN THE COMMUNITY (OTHER THAN THE
NCS RESEARCHERS) ......................................................................... 5
DOCTOR OR HEALTH CARE PROVIDER.............................................. 6
NEWSPAPER, T.V., OR RADIO .............................................................. 7
BILLBOARD ............................................................................................. 8
A LETTER IN THE MAIL .......................................................................... 9
OTHER (SPECIFY): _________________________________________ 10
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PS040. Have you taken part in any local or community activities sponsored by the National Children’s Study such as town
meetings, community forums, community advisory boards, health fairs, or other activities?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PS042)
REFUSED .......................................................................................... 9--97 (PS042)
DON’T KNOW .................................................................................... 9--98 (PS042)
PS041. Would you describe the event as
A health fair, that is an event with informational or health monitoring booths;
A meeting with at least one speaker who presents information to an audience;
A discussion group with a limited number of people participating; or
Something else?
HEALTH FAIR .......................................................................................... 1
MEETING ................................................................................................. 2
DISCUSSION GROUP ............................................................................. 3
SOMETHING ELSE (SPECIFY): _______________________________ 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PS042. These next few questions will help us to contact you again in the future.
BOX PS30
CHECK ITEM:
IF R WAS ENUMERATION RESPONDENT, GO TO PS047.
OTHERWISE, CONTINUE WITH PS043.
Appendix A
A.1.1.b–15
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
PS043. What is your last name?
INTERVIEWER INSTRUCTION:
CONFIRM SPELLING OF LAST NAME.
___________________________________
LAST NAME
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
PS044. What is the best phone number to reach you?
INTERVIEWER INSTRUCTION:
CONFIRM NUMBER.
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
PS045. Is that your home, work, cell, or another phone number?
INTERVIEWER INSTRUCTION:
CONFIRM IF KNOWN.
HOME....................................................................................................... 1 (PS047)
WORK ...................................................................................................... 2
CELL ........................................................................................................ 3
FRIEND/RELATIVE (SPECIFY): _______________________________ 4
OTHER (SPECIFY): _________________________________________ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PS046. What is your home telephone number?
|___|___|___| - |___|___|___| - |___|___|___|___|
NONE/NO LAND LINE .......................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--90
9--97
9--98
PS047. Is your mailing address the same as your street address?
YES .......................................................................................................... 1 (PS049)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (PS049)
DON’T KNOW .................................................................................... 9--98 (PS049)
Appendix A
A.1.1.b–16
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
PS048. What is your mailing address?
INTERVIEWER INSTRUCTION:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________________________
STREET/PO BOX
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
PS049. What is {your/{NAME’s}} birthdate?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX PS31
CHECK ITEM:
IF IN NO FOLLOW UP GROUP AND 18 OR OLDER, GO TO PSCLSE9.
IF IN NO FOLLOW UP GROUP AND REPORTED < 18 YEARS OLD AND
PREGNANT IN ENUMERATION AND STILL PREGNANT AT PREGNANCY
SCREENER, GO TO PSCLSE13.
OTHERWISE, CONTINUE WITH PS050.
PS050. Do you have an email address?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX PS32)
REFUSED .......................................................................................... 9--97 (BOX PS32)
DON’T KNOW .................................................................................... 9--98 (BOX PS32)
PS051. What is the best email address to reach you?
___________________________________
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.1.b–17
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
BOX PS32
CHECK ITEM:
IF IN PREGNANT ELIGIBLE GROUP AND 18 OR OLDER, CONTINUE WITH
PS052.
IF IN PREGNANT ELIGIBLE GROUP AND < 18, GO TO PSCLSE12.
IF IN HOLDING GROUP AND PREGNANT, GO TO PSCLSE5.
IF IN HOLDING GROUP AND NO LONGER PREGNANT, GO TO PSCLSE14.
IF IN HIGH GROUP, GO TO PS058.
IF IN MODERATE/LOW GROUP, GO TO PSCLSE7.
IF IN EXTRA LOW GROUP, GO TO PSCLSE8.
PS052. Do you plan on moving from your present address before you have your baby?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PSCLSE4)
REFUSED .......................................................................................... 9--97 (PSCLSE4)
DON’T KNOW .................................................................................... 9--98 (PSCLSE4)
PS053. Do you know where you will be moving?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PS056)
REFUSED .......................................................................................... 9--97 (PS056)
DON’T KNOW .................................................................................... 9--98 (PS056)
PS054. What is the address of your new home?
ADDRESS GIVEN.................................................................................... 1
OUT OF THE COUNTRY ......................................................................... 0
PO BOX ADDRESS ONLY....................................................................... 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(PS056)
(PS056)
(PS056)
(PS056)
PS055.
INTERVIEWER INSTRUCTION: PROBE AND ENTER AS MUCH INFORMATION AS R KNOWS.
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
Appendix A
A.1.1.b–18
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
PS056. Do you know when you will be moving?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX PS33)
REFUSED .......................................................................................... 9--97 (BOX PS33)
DON’T KNOW .................................................................................... 9--98 (BOX PS33)
PS057. When will you move?
INTERVIEWER INSTRUCTION:
CONFIRM IF KNOWN.
ENTER AS MUCH AS R KNOWS.
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX PS33
CHECK ITEM:
IF MOVING AND KNOW WHERE MOVING TO, GO TO PSCLSE11.
OTHERWISE, GO TO PSCLSE4.
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?
ADDRESS GIVEN.................................................................................... 1
OUT OF THE COUNTRY ......................................................................... 0
PO BOX ADDRESS ONLY....................................................................... 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(PS062)
(PS062)
(PS062)
(PS062)
Appendix A
A.1.1.b–19
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
PS061.
INTERVIEWER INSTRUCTION: PROBE AND ENTER AS MUCH INFORMATION AS R KNOWS.
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
PS062. Do you know when you will be moving?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX PS34)
REFUSED .......................................................................................... 9--97 (BOX PS34)
DON’T KNOW .................................................................................... 9--98 (BOX PS34)
PS063. When will you move?
INTERVIEWER INSTRUCTION:
CONFIRM IF KNOWN.
ENTER AS MUCH AS R KNOWS.
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX PS34
CHECK ITEM:
IF MOVING WITHIN TWO MONTHS AND KNOW WHERE MOVING TO, GO TO
PSCLSE11.
OTHERWISE, GO TO PSCLSE6.
PSCLSE4. Thank you for answering these questions. You have told us that you are currently pregnant. Because of your
expected due date, you are eligible to take part in this important study. We would like to set up a visit to tell
you more about it and give you all the information that you need to make your decision.
INTERVIEWER INSTRUCTIONS:
SCHEDULE T1 VISIT.
WHEN FINISHED, INQUIRE WHETHER ANY ADDITIONAL ELIGIBLE FEMALES ARE AVAILABLE.
Appendix A
A.1.1.b–20
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
BOX PS35
GO TO EOS.
PSCLSE5. Thank you for answering these questions. While you are too far along with your current pregnancy for your
baby to be a part of this study, we will contact you again about six months after your baby is born to see how
everything is going. Should you become pregnant again, that baby may be able to be part of our study.
INTERVIEWER INSTRUCTION:
WHEN FINISHED, INQUIRE WHETHER ANY ADDITIONAL ELIGIBLE FEMALES ARE AVAILABLE.
BOX PS36
GO TO EOS.
PSCLSE6. Thank you for answering these questions. Based on the information you’ve given me, you are eligible to take
part in this important study. We would like to set up an appointment to tell you more about it and give you all
the information that you need to make your decision.
INTERVIEWER INSTRUCTION:
SCHEDULE P1 VISIT.
WHEN FINISHED, INQUIRE WHETHER ANY ADDITIONAL ELIGIBLE FEMALES ARE AVAILABLE.
BOX PS37
GO TO EOS.
PSCLSE7. Thank you for answering these questions. We will give you a call in about three months to see if any of your
information has changed and to update our records.
INTERVIEWER INSTRUCTION:
WHEN FINISHED, INQUIRE WHETHER ANY ADDITIONAL ELIGIBLE FEMALES ARE AVAILABLE.
BOX PS38
GO TO EOS.
PSCLSE8. Thank you for answering these questions. We will give you a call in about six months to see if any of your
information has changed and to update our records.
INTERVIEWER INSTRUCTION:
WHEN FINISHED, INQUIRE WHETHER ANY ADDITIONAL ELIGIBLE FEMALES ARE AVAILABLE.
Appendix A
A.1.1.b–21
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
BOX PS39
GO TO EOS.
PSCLSE9. Thank you for answering these questions. Based on the information you’ve provided, you are not eligible for
this study at this time. However, we will call your household again sometime over the next few years to see if
any of your information has changed and to update our records.
INTERVIEWER INSTRUCTION:
WHEN FINISHED, INQUIRE WHETHER ANY ADDITIONAL ELIGIBLE FEMALES ARE AVAILABLE.
BOX PS40
GO TO EOS.
PSCLSE10. Thanks for letting me know. Based on the information you’ve provided, {NAME} is not eligible for this study
and she will not be able to take part in it. Thanks for your time.
INTERVIEWER INSTRUCTION:
WHEN FINISHED, INQUIRE WHETHER ANY ADDITIONAL ELIGIBLE FEMALES ARE AVAILABLE.
BOX PS41
GO TO EOS.
PSCLSE11. Since you will be moving soon, I need to speak with my supervisor to see if you are still eligible for this study.
If you are still eligible, I will contact you again shortly to give you the information that you need to decide if you
would like to be a part of this study.
BOX PS42
GO TO EOS.
PSCLSE12. It looks like {NAME} is eligible for this study. I’d like to set up an appointment to come back and talk to you and
{NAME} about it.
BOX PS43
GO TO EOS.
PSCLSE13. Thank you for answering these questions. Because of her due date, it looks like {NAME} is not eligible for this
study.
Appendix A
A.1.1.b–22
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
BOX PS44
GO TO EOS.
PSCLSE14. I’m so sorry to hear that you’ve lost your baby. I understand this can be a difficult time. Thanks for your time.
EOS
END MODULE 3, SECTION 1.
Start Module 4, Section 1
BOX PS45
CHECK ITEM:
IF MODULE 1, SECTION 1 STATUS IS “NOT DONE,” CASE IS NOT ELIGIBLE
FOR MODULE 4, GO TO EOS.
IF MODULE 3 STATUS IS “COMPLETE,” CASE IS NOT ELIGIBLE FOR
MODULE 4, GO TO EOS.
OTHERWISE, CONTINUE.
PS064. I have just a few quick questions left. Before today, had you heard about the National Children’s Study?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PSCLSE15)
REFUSED .......................................................................................... 9--97 (PSCLSE15)
DON’T KNOW .................................................................................... 9--98 (PSCLSE15)
PS064. How did you hear about the National Children’s Study?
INTERVIEWER INSTRUCTION:
SELECT ALL THAT APPLY.
FRIENDS OR ACQUAINTANCES ........................................................... 1
FAMILY MEMBERS ................................................................................. 2
CHURCH, SYNAGOGUE, OR OTHER RELIGIOUS AFFILIATION......... 3
A COMMUNITY LEADER......................................................................... 4
SOMEONE ELSE IN THE COMMUNITY (OTHER THAN THE
NCS RESEARCHERS) ......................................................................... 5
DOCTOR OR HEALTH CARE PROVIDER.............................................. 6
NEWSPAPER, T.V., OR RADIO .............................................................. 7
BILLBOARD ............................................................................................. 8
A LETTER IN THE MAIL .......................................................................... 9
OTHER (SPECIFY): _________________________________________ 10
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.1.b–23
Version 1/20/08
Visit Type:Initial Pregnancy Screener
Target: Eligible Women
PS066. Have you taken part in any local or community activities sponsored by the National Children’s Study such as town
meetings, community forums, community advisory boards, health fairs, or other activities?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PSCLSE15)
REFUSED .......................................................................................... 9--97 (PSCLSE15)
DON’T KNOW .................................................................................... 9--98 (PSCLSE15)
PS067. Would you describe the event as
A health fair, that is an event with informational or health monitoring booths;
A meeting with at least one speaker who presents information to an audience;
A discussion group with a limited number of people participating; or
Something else?
HEALTH FAIR .......................................................................................... 1
MEETING ................................................................................................. 2
DISCUSSION GROUP ............................................................................. 3
SOMETHING ELSE (SPECIFY): _______________________________ 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PSCLSE15. Those are all the questions I have right now. Thanks for your time.
EOS
END MODULE 4, SECTION 1.
PS END
END PREGNANCY SCREENER.
Appendix A
A.1.1.c–1
Neighbor Information (Eligibility) Form
INTRODUCTION: Hello, I’m (NAME) and am working with (LOCAL STUDY CENTER) on
a large study of children’s health for the National Institutes of Health (SHOW ID BADGE). The
study is called the National Children’s Study. I have been trying to contact the people who live
at (TARGET DU ADDRESS).
Neighbor
1. Is there anyone living at (TARGET DU
ADDRESS)?
2. Are there any women ages 18 to 49 living there?
3. When is a good time to find someone at home?
ENTER ALL THAT APPLY
4. In case my supervisor wants to check my work, I
would like to have your name, address, and phone
number.
YES .........
NO ..........
DK ..........
RF ...........
1
2 (END)
7 (END)
8 (END)
YES .........
NO ..........
DK ..........
RF ...........
1
2
7 (END)
8 (END)
Time:
a.m.
p.m.
Days:
Before noon:
12 noon -4 pm:
4 pm- 8pm:
Name: _____________
Address: ____________
___________________
___________________
Phone: _____________
END: Thank you for your time.
Comments: _________________________________________________________________
___________________________________________________________________________
Appendix A
A.1.2.a–1
Version 1/20/08
Visit Type: P1
Target: Mother
P1 Visit: Interview Introduction
IN001.
Thank you for agreeing to participate in this study. We are about to begin the interview portion of today’s home
visit, which will take about 30 minutes to complete. Your answers are important to us. There are no right or wrong
answers, just those that help us to understand your situation. There are questions about where you live, your
lifestyle routines, and your health during this interview and you can always refuse to answer any question or
group of questions. If you need a bathroom break at any time please let me know so that I can give you the
materials to collect the samples that are needed today.
Before we start, can you get the medicines and any pesticide products that you were asked to gather for this
appointment?
IN002
AFTER RESPONDENT GATHERS MATERIALS, OR INDICATES THAT SHE DOESN’T HAVE ANY TO
GATHER, SAY:
Are you ready to begin?
YES ..........................................................................................................
NO ............................................................................................................
1
2 (END INTERVIEW)
Appendix A
A.1.2.a–2
Version 1/20/08
Visit Type: P1
Target: Mother
P1 Visit: Household Composition and Demographics: Part 1
DE001. First, I’d like to get some information about the people who live here.
DE002. How many people, both children and adults, live in this household? Include any persons who usually stay here but
are temporarily away on business, vacation, in the hospital, on full-time active military duty, or students living
temporarily away from home. Do not include anyone who is in a nursing home or other institution. Including
yourself, what is the total number of people who live here?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX DE01
CHECK ITEM:
IF DE002 = “1”, GO TO DE008.
OTHERWISE, CONTINUE WITH DE003.
DE003. Now I’d like to ask some questions about each person in your household, starting with the oldest. Please list
everyone who lives here, except yourself.
DE004. NAME
DE005. AGE
DE006. GENDER
DE007. RELATIONSHIP
__________________
UNIQUE FIRST NAME
|___|___|___|
AGE
REFUSED .............. 9--97
DON’T KNOW ........ 9--98
REFUSED .......... 9--97
DON’T KNOW .... 9--98
MALE........................... 1
FEMALE ...................... 2
REFUSED .............. 9--97
DON’T KNOW......... 9--98
SELF ..................................................
SPOUSE.............................................
BIOLOGICAL SON/DAUGHTER ........
ADOPTED SON/DAUGHTER ............
STEPSON/STEPDAUGHTER ............
BROTHER/SISTER ............................
FATHER/MOTHER.............................
GRANDCHILD....................................
PARENT-IN-LAW ...............................
SON-IN-LAW/DAUGHTER-IN-LAW ...
ROOMER, BOARDER........................
HOUSEMATE, ROOMMATE..............
UNMARRIED PARTNER....................
FOSTER CHILD .................................
OTHER NONRELATIVE.....................
OTHER RELATIVE.............................
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
Appendix A
A.1.2.a–3
Version 1/20/08
Visit Type: P1
Target: Mother
DE008. Now I’d like to ask about your marital status. What is your current marital status? Are you:
INTERVIEWER INSTRUCTION:
CONFIRM IF KNOWN.
Married, .................................................................................................... 01
Not married but living together with a partner of the opposite sex,........... 02
Not married but living together with a partner of the same sex,................ 03
Widowed,.................................................................................................. 04
Divorced, .................................................................................................. 05
Separated, or............................................................................................ 06
Never been married?................................................................................ 07
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BEGIN LOOP DE01
ASK DE009-DE012 ABOUT RESPONDENT.
CYCLE THROUGH AND ASK DE009-DE012 ABOUT SPOUSE OR RESIDENT
PARTNER IF APPLICABLE (RECORD CODED “1” OR “12” IN DE007).
DE009. {Do you/Does {NAME}} consider {yourself/(himself/herself)} to be Hispanic, or Latino/a?
INTERVIEWER INSTRUCTION:
IF ASKING ABOUT A FEMALE HOUSEHOLD MEMBER READ LATINA.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DE011)
REFUSED ..........................................................................................
9--7 (DE011)
DON’T KNOW ....................................................................................
9--8 (DE011)
DE010. Please give me the number of the group that represents {your/NAME’s} Hispanic origin or ancestry.
SHOW CARD DE2.
PUERTO RICAN ...................................................................................... 01
CUBAN/CUBAN AMERICAN ................................................................... 02
DOMINICAN (REPUBLIC)........................................................................ 03
MEXICAN ................................................................................................. 04
MEXICAN AMERICAN ............................................................................. 05
CENTRAL OR SOUTH AMERICAN ......................................................... 06
OTHER..................................................................................................... 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.2.a–4
Version 1/20/08
Visit Type: P1
Target: Mother
DE011. What race {do/does} {you/NAME} consider {yourself/(himself/herself)} to be?
PROBE: Anything else?
SELECT ALL THAT APPLY.
White, ....................................................................................................... 1
Black or African American, ....................................................................... 2
Asian, ....................................................................................................... 3
Native Hawaiian or Other Pacific Islander, ............................................... 4
American Indian or Alaska Native, or ....................................................... 5
Some other race? (SPECIFY): _________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DE012. Please look at the card and tell me what is the highest degree or level of school that {you/NAME} {have/has}
completed?
SHOW CARD DE3.
NO SCHOOL............................................................................................ 01
ELEMENTARY
NURSERY SCHOOL TO 4TH GRADE ...................................................... 02
5TH–6TH GRADE ....................................................................................... 03
7TH–8TH GRADE ....................................................................................... 04
HIGH SCHOOL
9TH GRADE ..............................................................................................
10TH GRADE ............................................................................................
11TH GRADE ............................................................................................
12TH GRADE (NO DIPLOMA)...................................................................
HIGH SCHOOL DIPLOMA .......................................................................
GED OR EQUIVALENT............................................................................
COLLEGE
SOME COLLEGE CREDITS, BUT LESS THAN 1 YEAR.........................
1 OR MORE YEARS OF COLLEGE, BUT NO DEGREE.........................
ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR
VOCATIONAL PROGRAM.......................................................................
ASSOCIATE DEGREE: ACADEMIC PROGRAM ....................................
BACHELOR’S DEGREE (e.g., BA, BS)....................................................
05
06
07
08
09
10
11
12
13
14
15
GRADUATE
MASTER’S DEGREE (e.g., MA, MS, MSW, MEng, MBA) ....................... 16
PROFESSIONAL SCHOOL DEGREE (e.g., MD, DDS, DVM, JD)........... 17
DOCTORAL DEGREE (e.g., Ph.D., Ed.D.) .............................................. 18
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.2.a–5
Version 1/20/08
Visit Type: P1
Target: Mother
END LOOP DE01
ASK DE009-DE012 ABOUT SPOUSE OR RESIDENT PARTNER IF
APPLICABLE (RECORD CODED “1” OR “12” IN DE007).
WHEN COMPLETE, CONTINUE WITH NEXT SECTION.
IF NO SPOUSE OR RESIDENT PARTNER (NO RECORD CODED “1” OR “12”
IN DE007), CONTINUE WITH NEXT SECTION.
Appendix A
A.1.2.a–6
Version 1/20/08
Visit Type: P1
Target: Mother
P1 Visit: Health Behaviors Part 1
HB001. The following questions are about your sleep habits during the past 7 days.
HB002. Thinking of the past 7 days, on a typical day, how much time did you sleep at night?
|___|___|
HOURS
|___|___|
MINUTES
Less than 4 hours,.................................................................................... 1
4–5 hours, ................................................................................................ 2
6–7 hours, ................................................................................................ 3
8–9 hours, or ............................................................................................ 4
10 or more hours? .................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB003. During the past 7 days, on a typical day, how much additional time did you sleep during the day?
|___|___|
HOURS
|___|___|
MINUTES
Not at all, .................................................................................................. 1
Less than 1 hour,...................................................................................... 2
1–2 hours, or ............................................................................................ 3
More than 2 hours? .................................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB004. Next, I’m going to ask about the time you spent being physically active in the last 7 days.
Please answer each question even if you do not consider yourself to be an active person. Think about the
activities you do at work, as part of your house or yard work, to get from place to place, and in your spare time for
recreation, exercise or sport.
Now, think about all the vigorous activities that take hard physical effort that you did in the last 7 days. Vigorous
activities make you breathe much harder than normal and may include heavy lifting, digging, aerobics, or fast
bicycling. Think only about those activities that you did during the last 7 days for at least 10 minutes at a time.
HB005. During the last 7 days, on how many days did you do vigorous physical activities?
|___|
NUMBER OF DAYS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (HB008)
9--98 (HB008)
Appendix A
A.1.2.a–7
Version 1/20/08
Visit Type: P1
Target: Mother
BOX HB01
CHECK ITEM:
IF HB005 = 0, GO TO HB008.
OTHERWISE, CONTINUE WITH HB006.
HB006. On average, how much time did you usually spend doing vigorous physical activities on each of those days?
PROBE: IF RESPONDENT GIVES AN ANSWER THAT IS LESS THAN 10 MINUTES: “Please think only of
activities that you have done for at least 10 minutes at a time.”
|___|___|
HOURS
|___|___| (HB008)
MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (HB008)
9--98
HB007. How much time in total did you spend over the last 7 days doing vigorous physical activities?
|___|___|
HOURS
|___|___|
MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
HB008. Now think about activities which take moderate physical effort that you did in the last 7 days. Moderate physical
activities make you breathe somewhat harder than normal and may include carrying light loads, bicycling at a
regular pace, or doubles tennis. Do not include walking. Again, think about only those physical activities that you
did for at least 10 minutes at a time.
HB009. During the last 7 days, on how many days did you do moderate physical activities?
|___|
NUMBER OF DAYS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
BOX HB02
CHECK ITEM:
IF HB009 = 0, GO TO HB012.
OTHERWISE, CONTINUE WITH HB010.
9--97 (HB012)
9--98 (HB012)
Appendix A
A.1.2.a–8
Version 1/20/08
Visit Type: P1
Target: Mother
HB010. On average, how much time did you usually spend doing moderate physical activities on each of those days?
PROBE: IF RESPONDENT GIVES AN ANSWER THAT IS LESS THAN 10 MINUTES: “Please think only of
activities that you have done for at least 10 minutes at a time.”
|___|___|
HOURS
|___|___| (HB012)
MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (HB012)
9--98
HB011. What is the total amount of time you spent over the last 7 days doing moderate physical activities?
|___|___|
HOURS
|___|___|
MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
HB012. Now think about the time you spent walking in the last 7 days. This includes at work and at home, walking to
travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or
leisure.
HB013. During the last 7 days, on how many days did you walk for at least 10 minutes at a time?
|___|
NUMBER OF DAYS PER WEEK
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (HB016)
9--98 (HB016)
BOX HB03
CHECK ITEM:
IF HB013 = 0, GO TO HB016.
OTHERWISE, CONTINUE WITH HB014.
HB014. On average, how much time did you usually spend walking on each of those days?
PROBE: IF RESPONDENT GIVES AN ANSWER THAT IS LESS THAN 10 MINUTES: “Please think only of
activities that you have done for at least 10 minutes at a time.”
|___|___|
HOURS
|___|___| (HB016)
MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (HB016)
9--98
Appendix A
A.1.2.a–9
Version 1/20/08
Visit Type: P1
Target: Mother
HB015. What is the total amount of time you spent walking over the last 7 days?
|___|___|
HOURS
|___|___|
MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
HB016. Overall, how would you say your activity level has changed since you found out you were pregnant? Has it…
Stayed the same as before you were pregnant, ....................................... 1
Increased a lot,......................................................................................... 2
Increased a little, ...................................................................................... 3
Decreased a little, or ................................................................................ 4
Decreased a lot? ...................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB017. Now I’d like to change topics and ask you some questions about drinking beverages with caffeine.
HB018. Currently, do you drink:
IF YES: On average, how many of these drinks do you have per day?
INTERVIEWER INSTRUCTION:
IF ANSWER IS “NO” WRITE IN “0” FOR HOW MANY PER DAY.
IF RESPONDENT DRINKS LESS THAN 1 DRINK PER DAY, WRITE IN “0” FOR HOW MANY PER DAY.
a.
b.
c.
d.
Caffeinated coffee? ..................................................................
Caffeinated tea? .......................................................................
Soda with caffeine (Coke, Pepsi, Dr. Pepper, Mountain Dew)?
Energy drinks with caffeine (Red Bull, Amp)? ..........................
YES
NO
1
1
1
1
2
2
2
2
HOW MANY
PER DAY
RF
|___|___|
|___|___|
|___|___|
|___|___|
9--97
9--97
9--97
9--97
DK
9--98
9--98
9--98
9--98
Appendix A
A.1.2.a–10
Version 1/20/08
Visit Type: P1
Target: Mother
P1 Visit: Use of Medicines, Supplements and Alternative Medicines
UM001. The next questions are about your use of prescription medications, over-the-counter medications, and dietary
supplements.
UM002. In the past 30 days, have you used or taken medication for which a prescription is needed? Include only those
products prescribed by a health professional such as a doctor or dentist. Please include prescription vitamins or
minerals.
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM003. In the past 30 days, have you used or taken any over-the-counter or nonprescription medications, or any
nonprescription vitamins, minerals, herbals, or other dietary supplements? This card lists some examples of
different types of over-the-counter medications, vitamins, minerals, and dietary supplements.
SHOW CARD UM1.
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX UM01
CHECK ITEM:
IF UM002 OR UM003, = “1,” CONTINUE WITH UM004.
OTHERWISE, GO TO EOS.
UM004. May I please see the containers for all the {prescriptions,} {and} {non-prescription medicines and supplements},
that you used or took in the past 30 days?
RESPONDENT HAS CONTAINERS........................................................
RESPONDENT DOES NOT HAVE CONTAINERS..................................
BOX UM02
CHECK ITEM:
IF UM002 = “1,” CONTINUE WITH UM005.
OTHERWISE, GO TO BOX UM04.
1
2
Appendix A
A.1.2.a–11
Version 1/20/08
Visit Type: P1
Target: Mother
UM005. I will start with the prescription medications. {Please show me any you have taken in the past 30 days/Please tell
me the names of the prescription medications and supplements that you have taken in the past 30 days}.
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER.
ACTIVATE LOOKUP AND SELECT MEDICATIONS FROM LIST. IF A MEDICATION IS NOT ON LIST, ENTER
THE FULL NAME (INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
PRODUCT ON PRESCRIPTION MEDICINE LIST .................................. 1
PRODUCT NOT ON LIST (SPECIFY): __________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BEGIN LOOP UM01
LOOP:
CYCLE THROUGH UM006–UM011 FOR EACH PRESCRIPTION.
UM006. First let’s talk about {MEDICATION}.
UM007. PRODUCT LABEL SEEN?
YES ..........................................................................................................
NO ............................................................................................................
1
2
UM008. RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK:
How is the {MEDICATION} taken?
By mouth, ................................................................................................ 01
Inhaled either by mouth or nose, .............................................................. 02
Injected,.................................................................................................... 03
Applied to the skin, such as a patch or creams, or ................................... 04
Some other way? (SPECIFY): _________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM009. Are you still taking {MEDICATION}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.2.a–12
Version 1/20/08
Visit Type: P1
Target: Mother
UM010. How often {do/did} you use or take {MEDICATION}?
|___|___|
ENTER NUMBER
ENTER UNIT
PER DAY..................................................................................................
PER WEEK ..............................................................................................
PER MONTH............................................................................................
PER YEAR ...............................................................................................
AS NEEDED.......................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
9--95
9--97
9--98
END LOOP UM01
LOOP:
CYCLE THROUGH UM006–UM010 FOR THE NEXT PRESCRIPTION
MEDICATION IN ROSTER.
WHEN FINISHED WITH ALL MEDICATIONS LISTED IN ROSTER CONTINUE
WITH UM011.
BOX UM03
CHECK ITEM:
IF UM003 = “1,” CONTINUE WITH UM011.
OTHERWISE, GO TO EOS.
UM011. Now let’s talk about your use of over-the-counter medications and nonprescription vitamins, minerals,
herbals, and other dietary supplements. {Please show me any you have taken in the past 30 days/Please tell
me the names of the nonprescription medications and nonprescription vitamins, minerals, herbals, and
supplements that you have taken in the past 30 days}
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER.
ACTIVATE LOOKUP AND SELECT PRODUCT FROM LIST. IF PRODUCT NOT ON LIST, ENTER THE FULL
NAME (INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
SHOW CARD UM1.
PRODUCT ON MEDICINE LIST .............................................................. 1
PRODUCT NOT ON LIST (SPECIFY): __________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.2.a–13
Version 1/20/08
Visit Type: P1
Target: Mother
BEGIN LOOP UM02
LOOP:
CYCLE THROUGH UM012–UM016 FOR EACH OTC.
UM012. Let’s talk about {PRODUCT}.
UM013. WAS PRODUCT LABEL SEEN?
YES ..........................................................................................................
NO ............................................................................................................
1
2
UM014. RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK:
How is the {PRODUCT} taken?
By mouth, ................................................................................................ 01
Inhaled either by mouth or nose, .............................................................. 02
Injected,.................................................................................................... 03
Applied to the skin, such as a patch or creams, or ................................... 04
Some other way? (SPECIFY): _________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM015. {In the past 30 days/Since you became pregnant}, how often have you taken {PRODUCT}:
Less than once a month, .......................................................................... 01
Once a month,.......................................................................................... 02
2–3 times a month (but less than once a week), ...................................... 03
1–2 times a week, .................................................................................... 04
3–4 times a week, .................................................................................... 05
5–6 times a week, or ................................................................................ 06
Every day? ............................................................................................... 07
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM016. Are you still taking {PRODUCT}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP UM02
LOOP:
CYCLE THROUGH UM012–UM016 FOR THE NEXT OTC IN ROSTER.
WHEN FINISHED WITH ALL OTCS LISTED IN ROSTER CONTINUE WITH
NEXT SECTION.
Appendix A
A.1.2.a–14
Version 1/20/08
Visit Type: P1
Target: Mother
P1 Visit: Pets and Pesticide Use
PP001. Now I’d like to ask about any pets you may have.
PP002. Are there any pets that spend any time inside your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PP008)
REFUSED .......................................................................................... 9--97 (PP008)
DON’T KNOW .................................................................................... 9--98 (PP008)
PP003. What kind of pets are these?
SELECT ALL THAT APPLY.
DOG ......................................................................................................... 1
CAT .......................................................................................................... 2
SMALL MAMMAL (RABBIT, GERBIL, HAMSTER, GUINEA PIG,
FERRET, MOUSE)................................................................................ 3
BIRD......................................................................................................... 4
FISH OR REPTILE (TURTLE, SNAKE, LIZARD)..................................... 5
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PP004. Are any products ever used on your pets to control fleas, ticks, or mites? This includes flea collars, flea and tick
powders, shampoos, or other flea, tick, and mite control products. (This does not include pills given to your pet to
control for fleas or other insects.)
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PP008)
REFUSED .......................................................................................... 9--97 (PP008)
DON’T KNOW .................................................................................... 9--98 (PP008)
PP005. When were any of these last used on any of your pets?
Within the last month, ............................................................................... 1
1–3 months ago,....................................................................................... 2
4–6 months ago, or .................................................................................. 3
More than 6 months ago?......................................................................... 4 (PP008)
REFUSED .......................................................................................... 9--97 (PP008)
DON’T KNOW .................................................................................... 9--98 (PP008)
Appendix A
A.1.2.a–15
Version 1/20/08
Visit Type: P1
Target: Mother
PP006. What are the names of the products used on your pets to control fleas, ticks, or mites? Please show me the
products or containers if you have them.
_____________________________________________________
ENTER PRODUCT NAME FROM LIST
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
PP007. Did you personally handle or apply any of these products to your pets?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PP008. I would now like to ask about products that may have ever been used in your home or yard to control for ants,
termites, cockroaches, bees, wasps, moths, or other insects during the past 6 months.
PP009. When were any pesticides last used inside or outside this residence to control for insects?
Within the last month, ............................................................................... 1
1–3 months ago,....................................................................................... 2
4–6 months ago,....................................................................................... 3
More than 6 months ago, or ..................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(EOS)
(EOS)
(EOS)
(EOS)
PP010. In preparation for this interview, we asked that you gather together any of the pesticide cans or containers you
may have used in the last 6 months. You may also have letters from building maintenance about pesticide
application, or receipts from the exterminator that list which products were used. Please show me, or tell me the
names of the products that have been used within the last 6 months, either indoors or outdoors, to treat for
insects?
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT, LETTER, OR RECEIPT IS PROVIDED.
_____________________________________________________
PRODUCT NAME FROM LIST
_____________________________________________________
REGISTRATION NUMBER IF KNOWN
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (EOS)
9--98 (EOS)
Appendix A
A.1.2.a–16
Version 1/20/08
Visit Type: P1
Target: Mother
BEGIN LOOP PP01
LOOP:
CYCLE THROUGH PP011–PP016 FOR ALL INSECTICIDE PRODUCTS LISTED
IN PP010.
PP011. How was the {PRODUCT} applied?
SELECT ALL THAT APPLY.
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT IS PROVIDED.
SPRAY ..................................................................................................... 01
BOMB....................................................................................................... 02
POWDER ................................................................................................. 03
STRIP....................................................................................................... 04
MOTH BALLS........................................................................................... 05
FOAM ....................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PP012. Which of the following areas of your home were treated with {PRODUCT}? Was it…
YES
NO
RF
DK
1
1
1
1
1
1
1
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
1
2
9--97
9--98
a. The common living area, that is the room other than bedroom or
kitchen where you spend most of your time?......................................
b. The kitchen? .......................................................................................
c. Your bedroom? ...................................................................................
d. The basement?...................................................................................
e. Any other rooms? ...............................................................................
f. Outdoors, around the walls of your house or building?.......................
g. Outdoors, in the garden or yard? ........................................................
h. Common areas inside building but outside of your home or
apartment (public foyer or hallway, etc.)? ...........................................
PP013. Who applied the {PRODUCT}? Was it….
You, .......................................................................................................... 1
A professional exterminator, or................................................................. 2
Someone else? ........................................................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.2.a–17
Version 1/20/08
Visit Type: P1
Target: Mother
PP014. How often was the {PRODUCT} used in the past 6 months?
More than once a month, or ..................................................................... 1
Once a month or less? ............................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX PP03
CHECK ITEM:
IF PP013 = “1,” CONTINUE WITH PP015.
OTHERWISE, GO TO END LOOP PP01.
PP015. When you applied the {PRODUCT}, did you usually wear any protective items such as gloves or a mask?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_PP01)
REFUSED .......................................................................................... 9--97 (EL_PP01)
DON’T KNOW .................................................................................... 9--98 (EL_PP01)
PP016. Which protective items did you wear?
SELECT ALL THAT APPLY.
GLOVES................................................................................................... 1
MASK ....................................................................................................... 2
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP PP01
LOOP:
CYCLE THROUGH PP011–PP016 FOR NEXT INSECTICIDE PRODUCT.
IF NO MORE PRODUCTS, GO TO NEXT SECTION.
Appendix A
A.1.2.a–18
Version 1/20/08
Visit Type: P1
Target: Mother
P1 Visit: Occupational/Hobby Exposures
OH001. Now I would like to ask some questions about any schoolwork, jobs, volunteer work, and hobbies that you have
done recently. Please only include activities that you do (or have done) for 4 hours a week or longer.
OH002. Are you currently a full- or part-time student? This includes vocational or technical schooling that may not be done
in a classroom.
PROBE: Do you go full-time or part-time?
NO, NOT A STUDENT ............................................................................. 1 (OH007)
YES, FULL-TIME STUDENT.................................................................... 2
YES, PART-TIME STUDENT ................................................................... 3
REFUSED .......................................................................................... 9--97 (OH007)
DON’T KNOW .................................................................................... 9--98 (OH007)
OH003. What type of school are you currently attending?
HIGH SCHOOL ........................................................................................ 1
TECHNICAL SCHOOL ............................................................................. 2
COLLEGE OR UNIVERSITY.................................................................... 3
GRADUATE SCHOOL ............................................................................. 4
PROFESSIONAL SCHOOL (E.G., MEDICAL, LAW, DENTAL) ............... 5
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH004. Please refer to this card and tell me, what best describes the place where you typically go to school?
SHOW CARD OH1.
SELECT ALL THAT APPLY.
CLASSROOM .......................................................................................... 01
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S HOME . 02
LABORATORY......................................................................................... 03
GARAGE OR SHOP ................................................................................ 04
MOTOR VEHICLE.................................................................................... 05
SOME OTHER LOCATION (SPECIFY): _________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.2.a–19
Version 1/20/08
Visit Type: P1
Target: Mother
Section: OH; #11
OH005. What is the address where you actually attend school most often?
HOME....................................................................................................... 1
VARIES (CONSTRUCTION, LANDSCAPING) ........................................ 2
HAVE EXACT ADDRESS ........................................................................ 3
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(OH007)
(OH007)
(OH007)
(OH007)
(OH007)
OH006. (Please tell me the address where you actually attend school most often.)
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH007. Now I would like to ask you about the jobs you have had recently. {In the past 3 months/Since you became
pregnant}:
NUMBER
RF
DK
a. How many full-time jobs have you had? ......................................
b. How many part-time jobs have you had?.....................................
c. How many volunteer jobs have you had (fire department,
humane society, etc.)?.................................................................
|___|___|
|___|___|
9--97
9--97
9--98
9--98
|___|___|
9--97
9--98
BOX OH01
CHECK ITEM:
ADD THE NUMBER OF FULL-TIME, PART-TIME, AND VOLUNTEER JOBS AND
CREATE TotalNumberOfJobs.
BOX OH02
CHECK ITEM:
IF TotalNumberOfJobs > 0, BEGIN LOOP OH01.
IF TotalNumberOfJobs = 0, GO TO OH020.
Appendix A
A.1.2.a–20
Version 1/20/08
Visit Type: P1
Target: Mother
Section: OH; #11
BEGIN LOOP OH01
LOOP:
CYCLE THROUGH BOX OH03–OH019 AS MANY TIMES AS THE NUMBER
CALCULATED IN TotalNumberOfJobs.
BOX OH03
CHECK ITEM:
IF TotalNumberOfJobs = 1, GO TO OH009.
OTHERWISE, CONTINUE WITH OH008.
OH008. {Now I’d like to ask some questions about each one of your jobs, starting with the job where you work the most
hours/Now think about the job where you work the next greatest number of hours}.
OH009. Are you currently employed at this job?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH010. For this job, what {is/was} your job title or occupation?
_____________________________________________________
JOB TITLE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH011. For this job, who {is/was} your employer?
_____________________________________________________
EMPLOYER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.2.a–21
Version 1/20/08
Visit Type: P1
Target: Mother
Section: OH; #11
OH012. What types of activities {do/did} you do most often at this job? For example, teach classes, work on the computer,
keep account books, file, photocopy, answer phone, wait tables, help customers, do lab work, or carpentry?
PROBE: Anything else?
_____________________________________________________
ACTIVITY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH013. In what kind of business or industry {is/was} this job? That is, what does this company make or do?
_____________________________________________________
INDUSTRY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH014. On average, how many hours a week {do/did} you usually work at this job?
|___|___|___|
NUMBER OF HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH015. {Does/Did} this include working a shift (starts/started) after 2 pm?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH016. {Do/Did} you rotate among different shifts for this job?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.2.a–22
Version 1/20/08
Visit Type: P1
Target: Mother
Section: OH; #11
OH017. Please look at this card and tell me, what best describes the place where you typically {work/worked} for this job?
PROBE: Is this indoors or outdoors?
SHOW CARD OH2.
SELECT ALL THAT APPLY.
OFFICE AREA ......................................................................................... 01
STORE ..................................................................................................... 02
CLASSROOM .......................................................................................... 03
HOTEL OR MOTEL.................................................................................. 04
RESTAURANT ......................................................................................... 05
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S HOME . 06
HEALTHCARE FACILITY OR HOSPITAL................................................ 07
LABORATORY......................................................................................... 08
FACTORY, PLANT, OR PRODUCTION AREA........................................ 09
WAREHOUSE.......................................................................................... 10
GARAGE OR SHOP ................................................................................ 11
SALON ..................................................................................................... 12
LOADING DOCK...................................................................................... 13
CONSTRUCTION SITE............................................................................ 14
GROUNDS, YARD, OR GARDEN ........................................................... 15
MOTOR VEHICLE.................................................................................... 16
SOME OTHER LOCATION (SPECIFY): _________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH018. What is the address where you actually {work/worked} at this job?
HOME....................................................................................................... 1
VARIES (CONSTRUCTION, LANDSCAPING) ........................................ 2
HAVE EXACT ADDRESS ........................................................................ 3
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH019. Please tell me the address where you actually {work/worked} at this job.
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
(EL_OH01)
(EL_OH01)
(EL_OH01)
(EL_OH01)
(EL_OH01)
Appendix A
A.1.2.a–23
Version 1/20/08
Visit Type: P1
Target: Mother
Section: OH; #11
END LOOP OH01
LOOP:
IF NUMBER OF CYCLES < TotalNumberOfJobs, CYCLE THROUGH BOX
OH03–OH019 AGAIN.
AFTER NUMBER OF CYCLES = TotalNumberOfJobs, CONTINUE WITH OH020.
OH020. Now I want to ask about any cleaning products, chemicals, pesticides, radiation, or bacteria or viruses that you
may have worked around or used during the past 3 months at any job, school, or hobby when answering these
questions. Please consider all jobs, schools, and hobbies that you do for at least 4 hours per week. Do not
include regular household use.
BEGIN LOOP OH02
LOOP:
CYCLE THROUGH OH021-OH029 FOR CLEANING PRODUCTS, CHEMICALS,
PESTICIDES, DUSTS, FUMES, RADIATION, AND BACTERIA OR VIRUSES.
OH021. (In any {full or part-time job,} {volunteer job,} {school,} {or} hobby have you used or worked around):
any {cleaning products, such as bleach, ammonia, or detergents/chemicals, such as paints, fuels, solvents, oils,
glues, or hair or nail products/pesticides that you’ve mixed or applied/dusts, including wood or mining dust/fumes
or gases, such as from anesthetic gases, ethylene oxide, welding or asphalt fumes, or engine exhaust/radiation,
including x-rays, fluoroscopy, or radioisotopes/bacteria or viruses, such as those used in a laboratory setting}?
(Again, do not include regular household use.)
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_OH02)
REFUSED .......................................................................................... 9--97 (EL_OH02)
DON’T KNOW .................................................................................... 9--98 (EL_OH02)
DISPLAY INSTRUCTIONS:
IF FIRST CYCLE, DISPLAY “{cleaning products, such as bleach, ammonia, or detergents}.”
IF SECOND CYCLE, DISPLAY “{chemicals, such as paints, fuels, solvents, oils, glues, or hair or nail products}.”
IF THIRD CYCLE, DISPLAY “{pesticides that you’ve mixed or applied}.”
IF FOURTH CYCLE, DISPLAY “{dusts, including wood or mining dust}.”
IF FIFTH CYCLE, DISPLAY “{fumes or gases, such as from anesthetic gases, ethylene oxide, welding or asphalt
fumes, or engine exhaust}.”
IF SIXTH CYCLE, DISPLAY “{radiation, including x-rays, fluoroscopy, or radioisotopes}.”
IF SEVENTH CYCLE, DISPLAY “{bacteria or viruses, such as those used in a laboratory setting}.”
OH022. Please tell me the name of (or describe) the {cleaning products/chemicals/pesticides/dusts/fumes or
gases/radiation/bacteria or viruses}?
_____________________________________________________
NAME OR DESCRIPTION OF EXPOSURE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.2.a–24
Version 1/20/08
Visit Type: P1
Target: Mother
Section: OH; #11
OH023. Do you handle or work directly with the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/
bacteria or viruses} or do you just work around it?
DON’T WORK DIRECTLY WITH THE MATERIAL .................................. 1
HANDLE DIRECTLY (POUR, TOUCH, ETC.) ......................................... 2
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH024. Now thinking of the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/bacteria or viruses}
that you just mentioned….
OH025. During the past 3 months, how often did you wear or use personal protective equipment to protect yourself from
the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/bacteria or viruses}? By personal
protective equipment, I mean things like gloves, dust masks, goggles, aprons, lab coats, or other protective
clothing. Would you say you always, often, rarely, or never use personal protective equipment?
ALWAYS .................................................................................................. 1
OFTEN ..................................................................................................... 2
RARELY ................................................................................................... 3
NEVER ..................................................................................................... 4 (OH028)
REFUSED .......................................................................................... 9--97 (OH028)
DON’T KNOW .................................................................................... 9--98 (OH028)
OH026. Please look at this card and tell me which types of protective clothing or equipment have you worn?
PROBE: Any other protective clothing or equipment?
SHOW CARD OH3.
SELECT ALL THAT APPLY.
GLOVES................................................................................................... 01
OVERALLS .............................................................................................. 02
OVERCOAT (E.G., LAB COAT, SMOCK, APRON) ................................. 03
DUST MASK ............................................................................................ 04
RESPIRATOR .......................................................................................... 05
GOGGLES/SAFETY GLASSES/FACE SHIELD ...................................... 06
WORK BOOTS/SHOES ........................................................................... 09
LEAD APRON .......................................................................................... 08
SOMETHING ELSE (SPECIFY): _______________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.2.a–25
Version 1/20/08
Visit Type: P1
Target: Mother
Section: OH; #11
OH027. What type of respirator was it?
A half-mask chemical cartridge respirator, which is silicone or rubber
and covers your mouth and nose, ......................................................... 1
A full-mask chemical cartridge respirator, which is silicone or rubber
and covers your eyes, nose, and mouth, ............................................... 2
An air-supplied or SCBA respirator, or .................................................... 3
Some other kind of respirator? (SPECIFY): _______________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH028. Is there any kind of a ventilation system to remove exhaust, dust, smoke or fumes from the area? By ventilation
system we mean purposely opening windows or doors, using a fume hood, or other ventilation system.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_OH02)
REFUSED .......................................................................................... 9--97 (EL_OH02)
DON’T KNOW .................................................................................... 9--98 (EL_OH02)
OH029. What ventilation systems are present to remove exhaust, dust, smoke or fumes from the area? Is there….
SELECT ALL THAT APPLY.
General ventilation, meaning open doors or windows, fans, etc............... 01
A regular HVAC system for building and room heating and cooling, ........ 02
A fume hood, lab hood, or other partially enclosed equipment,................ 03
A glove box or other totally enclosed equipment, ..................................... 04
A portable exhaust hose or tube, such as those used for welding or to
attach to vehicle tailpipe, or ................................................................... 05
Some other type of ventilation system? (SPECIFY): ________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP OH02
LOOP:
IF NUMBER OF CYCLES < 7 CYCLE AGAIN.
IF NUMBER OF CYCLES = 7, END LOOP AND CONTINUE WITH NEXT
SECTION.
Appendix A
A.1.2.a–26
Version 1/20/08
Visit Type: P1
Target: Mother
P1 Visit: Household Composition and Demographics: Part 2
DM001. These next questions are about your background and cultural heritage.
DM002. Were you born in the United States?
YES .......................................................................................................... 1 (DM005)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (DM005)
DON’T KNOW .................................................................................... 9--98 (DM005)
DM003. In what country were you born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DM004. About how long have you lived in the United States?
INTERVIEWER INSTRUCTION:
IF LESS THAN ONE YEAR, ENTER ”00”.
|___|___|
YEARS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DM005. Was your mother born in the United States?
YES .......................................................................................................... 1 (DM007)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (DM007)
DON’T KNOW .................................................................................... 9--98 (DM007)
DM006. In what country was your mother born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.2.a–27
Version 1/20/08
Visit Type: P1
Target: Mother
DM007. Was your father born in the United States?
YES .......................................................................................................... 1 (DM009)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (DM009)
DON’T KNOW .................................................................................... 9--98 (DM009)
DM008. In what country was your father born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DM009. These next questions are about the food eaten in your household in the last 12 months, and whether you were
able to afford the food you need.
DM010. Which of these statements best describes the food eaten in your household in the last 12 months:
Enough of the kinds of food we want to eat,............................................. 1
Enough, but not always the kinds of food we want,.................................. 2
Sometimes not enough food to eat, or ..................................................... 3
Often not enough food to eat?.................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(DM012)
(DM012)
(DM012)
(DM012)
DM011. Here are some reasons why people don’t always have enough to eat. For each one, please tell me if this is a
reason why you don’t always have enough to eat.
YES
NO
RF
DK
a.
b.
c.
d.
e.
f.
Not enough money for food? ..............................................................
Not enough time for shopping or cooking? .........................................
Too hard to get to the store? ..............................................................
On a diet? ...........................................................................................
No working stove available? ...............................................................
Not able to cook or eat because of health problems?.........................
1
1
1
1
1
1
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
DM012. Now I’m going to switch the subject and ask about health insurance.
DM013. Do you currently have insurance through a current or former employer or union (of yourself or another family
member)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.2.a–28
Version 1/20/08
Visit Type: P1
Target: Mother
DM014. (Do you currently have:)
Insurance purchased directly from an insurance company (by yourself or another family member)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM015. (Do you currently have:)
Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a
disability?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM016. (Do you currently have:)
TRICARE, VA, or other military health care?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM017. (Do you currently have:)
Indian Health Service?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM018. (Do you currently have:)
Medicare, for people 65 and older, or people with certain disabilities?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.2.a–29
Version 1/20/08
Visit Type: P1
Target: Mother
DM019. (Do you currently have:)
Any other type of health insurance or health coverage plan?
YES (SPECIFY): ___________________________________________ 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM020. Lastly, I’d like to find out how you see yourself in relation to other people in the United States.
DM021. Please look at this card. Think of this ladder as representing where people stand in the United States. At the
top of the ladder are the people who are the best off—those who have the most money, the most education and
the most respected jobs. At the bottom are the people who are the worst off—who have the least money, least
education, and the least respected jobs or no job.
Where would you place yourself on this ladder?
Please point to the rung where you think you stand at this time in your life, relative to other people in the United
States.
SHOW CARD DM1.
RUNG A ................................................................................................... 01
RUNG B ................................................................................................... 02
RUNG C ................................................................................................... 03
RUNG D ................................................................................................... 04
RUNG E ................................................................................................... 05
RUNG F.................................................................................................... 06
RUNG G ................................................................................................... 07
RUNG H ................................................................................................... 08
RUNG I..................................................................................................... 09
RUNG J .................................................................................................... 10
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.2.a–30
Version 1/20/08
Visit Type: P1
Target: Mother
P1 Mom Interview: Tracing Information
TR001. Finally, I need to ask you a few questions so that staff from the National Children’s Study may contact you again.
TR002. Sometimes if people move or change their telephone number, we have difficulty reaching them. Could I have the
names and telephone numbers of 1 or 2 friends or relatives not currently living with you who should know where
you could be reached in case we have trouble contacting you?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TR011)
REFUSED .......................................................................................... 9--97 (TR011)
DON’T KNOW .................................................................................... 9--98 (TR011)
TR003. I’d like to collect some basic contact information on this person/these people. What is the first person’s name?
________________
FIRST NAME
________________
LAST NAME
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (TR011)
9--98 (TR011)
TR004. What is his/her relationship to you?
MOTHER/FATHER .................................................................................. 01
BROTHER/SISTER.................................................................................. 02
AUNT/UNCLE .......................................................................................... 03
GRANDPARENT...................................................................................... 04
NEIGHBOR .............................................................................................. 05
FRIEND .................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TR005. What is his/her address?
_____________________________________________________
STREET
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (TR007)
9--98
Appendix A
A.1.2.a–31
Version 1/20/08
Visit Type: P1
Target: Mother
TR006. What is his/her telephone number?
I__I__I__I – I__I__I__I – I__I__I__I__I
PHONE NUMBER ....................................................................................
NONE .................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91
9--97
9--98
TR007. Now I’d like to collect information on a second contact. What is this person’s name?
______________
FIRST NAME
__________________
LAST NAME
NO SECOND CONTACT PROVIDED................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91 (TR011)
9--97 (TR011)
9--98 (TR011)
TR008. What is his/her relationship to you?
MOTHER/FATHER .................................................................................. 01
BROTHER/SISTER.................................................................................. 02
AUNT/UNCLE .......................................................................................... 03
GRANDPARENT...................................................................................... 04
NEIGHBOR .............................................................................................. 05
FRIEND .................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TR009. What is his/her address?
_____________________________________________________
STREET
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (TR011)
9--98
Appendix A
A.1.2.a–32
Version 1/20/08
Visit Type: P1
Target: Mother
TR010. What is his/her telephone number?
I__I__I__I – I__I__I__I – I__I__I__I__I
PHONE NUMBER ....................................................................................
NONE .................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91
9--97
9--98
TR011. Finally, could you please tell me your Social Security Number or Individual Taxpayer Identification Number? The
National Children’s Study may use your Social Security Number to conduct health-related research by linking your
survey data with vital statistics and other health records. We also may use it if we need to locate you or your
family in the future. Except for these purposes, the Study will not release your Social Security Number to anyone,
including any government agency. Providing this information is voluntary. Whether or not you give us this number
will have no effect on any benefits you might receive. The National Children’s Study is authorized by the
Children’s Health Act of 2000 and the Public Health Service Act. (The Public Health Service Act authority is found
under Section 448 (42USC 285g).
|___|___|___| |___|___| |___|___|___|___|
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TR012. Thank you for answering these questions. This completes the interview portion of the visit.
Appendix A
A.1.2.b–1
Version 1/20/08
Visit Type: Preconception 1 Month
Target: Enrolled Female
Preconception Phone Follow-Ups (1, 2, & 4 Mo.)
INTRO1. Hello, I’m calling today from the National Children’s Study to speak with {NAME}. Is she available now?
YES (TARGET ANSWERED PHONE) ..................................................... 1
YES (TARGET AVAILABLE) .................................................................... 2
NO ............................................................................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(START_FV)
(INTRO3)
(CLOSE1)
(INTRO3)
INTRO2. Hello, I’m calling today from the National Children’s Study to speak with {NAME}. Is this she?
INTERVIEWER INSTRUCTION:
WAIT FOR NEW PERSON TO PICK UP PHONE BEFORE BEGINNING QUESTION.
YES .......................................................................................................... 1 (START_FV)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (CLOSE1)
DON’T KNOW .................................................................................... 9--98
INTRO3. When would be a good day of the week and time to call her back?
CLOSE1. Thanks for your time. These are all the questions I have right now.
BOX FV00
CHECK ITEM:
IF R IN HIGH PPG GROUP AND REPORTED TRYING TO GET PREGNANT AT
LAST PPG ASSIGNMENT, GO TO FV003.
IF R IN HIGH PPG GROUP AND REPORTED NOT TRYING TO BECOME
PREGNANT AT LAST PPG ASSIGNMENT, GO TO FV001.
FV001. I’m calling today just to update some information we have for you. Last time we spoke, you weren’t trying to
become pregnant, but we know that plans to start a family can sometimes change.
FV002. Are you now
Trying to become pregnant,...................................................................... 1
Not trying to become pregnant, or............................................................ 2
Currently pregnant?.................................................................................. 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(BOX FV01)
(FV011)
(FV005)
(FV011)
(FV011)
Appendix A
A.1.2.b–2
Version 1/20/08
Visit Type: Preconception 1 Month
Target: Enrolled Female
FV004. Since we last spoke with you, have you learned that you’re pregnant?
YES ..........................................................................................................
NO ............................................................................................................
REFUSED ................................................................................................
DON’T KNOW ..........................................................................................
1 (FV005)
2
7
8
BOX FV01
CHECK ITEM:
IF R IS A NEW TRYER (FV002 = 1), GO TO FV010.
IF R IS A PREVIOUS TRYER (FV002 NOT ASKED), GO TO FV008.
FV005. Congratulations. When is your baby due?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ................................................................................................ 9—97
DON’T KNOW .......................................................................................... 9—98
(FV006)
(FV006)
BOX FV02
CHECK ITEM:
GO TO BOX FV06.
FV006. What was the first day of your last menstrual period?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (FV007)
9--98 (FV007)
BOX FV03
GO TO BOX FV06.
FV007. How many weeks pregnant are you now? If you’re not sure, please make your best guess.
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (BOX FV06)
9--98 (BOX FV06)
Appendix A
A.1.2.b–3
Version 1/20/08
Visit Type: Preconception 1 Month
Target: Enrolled Female
BOX FV04
GO TO BOX FV06.
FV008. Are you currently trying to become pregnant?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX FV06)
REFUSED .......................................................................................... 9--97 (BOX FV06)
DON’T KNOW .................................................................................... 9--98 (BOX FV06)
FV009. Please continue to use the pregnancy test kits the study gave you. Do you need any more pregnancy test kits?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(BOX FV06)
(BOX FV06)
(BOX FV06)
(BOX FV06)
FV010. Since you’re now trying to become pregnant, it’s important that some additional information be collected. The
study will send you some additional materials, including pregnancy test kits and instructions for collecting
additional information. These will arrive by mail in about a week.
BOX FV05
CHECK ITEM:
GO TO BOX FV06.
FV011. This next question is about birth control. The last time you had intercourse with a man, did you use any type of
contraception or do anything to prevent pregnancy?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX FV06)
REFUSED .......................................................................................... 9--97 (BOX FV06)
DON’T KNOW .................................................................................... 9--98 (BOX FV06)
Appendix A
A.1.2.b–4
Version 1/20/08
Visit Type: Preconception 1 Month
Target: Enrolled Female
FV012. Please listen to the following options and tell me all the types of contraception you used the last time you had
intercourse with a man. Did you use:
a.
b.
c.
d.
f.
g.
h.
i.
j.
k.
l.
m.
n.
Birth control pills? ...............................................................................
Condoms? ..........................................................................................
Depo-Provera, or other shots or injections? .......................................
Natural family planning, including rhythm or safe period
by calendar, temperature, or cervical mucus? ....................................
A diaphragm, cervical cap, or shield? .................................................
Foam, jelly, cream, suppository, or other insert? ................................
A female condom, or vaginal pouch?..................................................
The patch, Norplant, Nuva ring, or the ring?.......................................
The TODAY sponge? .........................................................................
An IUD, Coil, or Loop?........................................................................
Plan B or the “Morning After” pill?.......................................................
Withdrawal or pulling out? ..................................................................
Some other method or did something else? .......................................
YES
1
1
1
NO
2
2
2
RF
9--97
9--97
9--97
DK
9--98
9--98
9--98
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
BOX FV06
PROGRAMMER INSTRUCTION:
RUN ALGORITHM
BOX FV07
CHECK ITEM:
IF IN PREGNANT ELIGIBLE GROUP, GO TO FV013.
IF IN HOLDING GROUP, GO TO FV014.
IF IN HIGH GROUP AND TRYING TO BECOME PREGNANT, GO TO FV016.
IF IN HIGH GROUP AND NOT TRYING TO BECOME PREGNANT, GO TO
FV015.
IF IN MODERATE/LOW GROUP AND TRYING TO BECOME PREGNANT, GO
TO FV016.
IF IN MODERATE/LOW GROUP AND NOT TRYING TO BECOME PREGNANT,
GO TO FV015.
IF IN MODERATE/LOW GROUP AND NOT TRYING TO BECOME PREGNANT,
BUT REPORTED TRYING TO BECOME PREGNANT AT PREGNANCY
SCREENER, GO TO FV017.
IF IN EXTRA LOW GROUP, GO TO FV018.
FV013. {Congratulations again on your pregnancy.} Because you’re pregnant, we’d like to set up another visit at your
home to tell you about the next phase of this study.
BOX FV08
GO TO EOS.
Appendix A
A.1.2.b–5
Version 1/20/08
Visit Type: Preconception 1 Month
Target: Enrolled Female
FV014. {Congratulations again on your pregnancy.} While this study focuses on child health, at this time we are only
enrolling women whose babies are due between {DATE 1} and {DATE 2}. However, if you become pregnant
again, that baby may be eligible for the study later on. We’ll check in with you a few months after you baby is born
to see how you’re doing and update your information. Thanks for your time.
BOX FV09
GO TO EOS.
FV015. Thanks for your time. We’ll call you in a month or two to check in with you and see if anything has changed.
BOX FV10
GO TO EOS.
FV016. Thanks for your time. We’ll call you in a month or two to check in with you and see if anything has changed. In the
meantime, if you learn that you’re pregnant, please call [INSERT LOCAL PROCEDURES].
{We’ll mail the pregnancy test kits you requested. They will arrive in about a week.}
BOX FV11
GO TO EOS.
FV017. Thanks for your time. We understand that plans can change and that you’re not trying to become pregnant right
now. We’ll call you in a month or two to check in with you and see if anything has changed.
BOX FV12
GO TO EOS.
FV018. Thanks for your time. We’ll call you in about a year to check in with you and update your information.
FV_END
END P1 MONTH PHONE CALL
Appendix A
A.1.3.a–1
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Interview Introduction
IN001.
Thank you for agreeing to participate in this study. We are about to begin the interview portion of today’s home
visit, which will take about 60 minutes to complete. Your answers are important to us. There are no right or wrong
answers, just those that help us to understand your situation. There are questions about where you live, your
lifestyle routines, and your pregnancy during this interview and you can always refuse to answer any question or
group of questions. If you need a bathroom break at any time please let me know so that I can give you the
materials to collect the samples that are needed today.
Before we start, can you get the medicines and any pesticide products that you were asked to gather for this
appointment?
IN002.
AFTER RESPONDENT GATHERS MATERIALS, OR INDICATES THAT SHE DOESN’T HAVE ANY TO
GATHER, SAY:
Are you ready to begin?
YES ..........................................................................................................
NO ............................................................................................................
1
2 (END INTERVIEW)
Appendix A
A.1.3.a–2
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Household Composition and Demographics: Part 1
DE001. First, I’d like to get some information about the people who live here.
DE002. How many people, both children and adults, live in this household? Include any persons who usually stay here but
are temporarily away on business, vacation, in the hospital, on full-time active military duty, or students living
temporarily away from home. Do not include anyone who is in a nursing home or other institution. Including
yourself, what is the total number of people who live here?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX DE01
CHECK ITEM:
IF DE002 = “1,” GO TO DE008.
OTHERWISE, CONTINUE WITH DE003.
DE003. Now I’d like to ask some questions about each person in your household, starting with the oldest. Please list
everyone who lives here, except yourself.
DE004. NAME
DE005. AGE
DE006. GENDER
DE007. RELATIONSHIP
__________________
UNIQUE FIRST NAME
|___|___|___|
AGE
REFUSED .............. 9--97
DON’T KNOW ........ 9--98
REFUSED .......... 9--97
DON’T KNOW .... 9--98
MALE........................... 1
FEMALE ...................... 2
REFUSED .............. 9--97
DON’T KNOW......... 9--98
SELF ..................................................
SPOUSE.............................................
BIOLOGICAL SON/DAUGHTER ........
ADOPTED SON/DAUGHTER ............
STEPSON/STEPDAUGHTER ............
BROTHER/SISTER ............................
FATHER/MOTHER.............................
GRANDCHILD....................................
PARENT-IN-LAW ...............................
SON-IN-LAW/DAUGHTER-IN-LAW ...
ROOMER, BOARDER........................
HOUSEMATE, ROOMMATE..............
UNMARRIED PARTNER....................
FOSTER CHILD .................................
OTHER NONRELATIVE.....................
OTHER RELATIVE.............................
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
Appendix A
A.1.3.a–3
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DE008. Now I’d like to ask about your marital status. What is your current marital status? Are you:
INTERVIEWER INSTRUCTION:
CONFIRM IF KNOWN.
Married, .................................................................................................... 01
Not married but living together with a partner of the opposite sex,........... 02
Not married but living together with a partner of the same sex,................ 03
Widowed,.................................................................................................. 04
Divorced, .................................................................................................. 05
Separated, or............................................................................................ 06
Never been married?................................................................................ 07
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BEGIN LOOP DE01
ASK DE009–DE012 ABOUT RESPONDENT.
CYCLE THROUGH AND ASK DE009-DE012 ABOUT SPOUSE OR RESIDENT
PARTNER IF APPLICABLE (RECORD CODED “1” OR “12” IN DE007).
DE009. {Do you/Does {NAME}} consider {yourself/(himself/herself)} to be Hispanic, or Latino/a?
INTERVIEWER INSTRUCTION:
IF ASKING ABOUT A FEMALE HOUSEHOLD MEMBER READ LATINA.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DE011)
REFUSED ..........................................................................................
9--7 (DE011)
DON’T KNOW ....................................................................................
9--8 (DE011)
DE010. Please give me the number of the group that represents {your/NAME’s} Hispanic origin or ancestry.
SHOW CARD DE2.
PUERTO RICAN ...................................................................................... 01
CUBAN/CUBAN AMERICAN ................................................................... 02
DOMINICAN (REPUBLIC)........................................................................ 03
MEXICAN ................................................................................................. 04
MEXICAN AMERICAN ............................................................................. 05
CENTRAL OR SOUTH AMERICAN ......................................................... 06
OTHER..................................................................................................... 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–4
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DE011. What race {do/does} {you/NAME} consider {yourself/(himself/herself)} to be?
PROBE: Anything else?
SELECT ALL THAT APPLY.
White, ....................................................................................................... 1
Black or African American, ....................................................................... 2
Asian, ....................................................................................................... 3
Native Hawaiian or Other Pacific Islander, ............................................... 4
American Indian or Alaska Native, or ....................................................... 5
Some other race? (SPECIFY): _________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DE012. Please look at the card and tell me what is the highest degree or level of school that {you/NAME} {have/has}
completed?
SHOW CARD DE3.
NO SCHOOL............................................................................................ 01
ELEMENTARY
NURSERY SCHOOL TO 4TH GRADE ...................................................... 02
5TH–6TH GRADE ....................................................................................... 03
7TH–8TH GRADE ....................................................................................... 04
HIGH SCHOOL
9TH GRADE ..............................................................................................
10TH GRADE ............................................................................................
11TH GRADE ............................................................................................
12TH GRADE (NO DIPLOMA)...................................................................
HIGH SCHOOL DIPLOMA .......................................................................
GED OR EQUIVALENT............................................................................
COLLEGE
SOME COLLEGE CREDITS, BUT LESS THAN 1 YEAR.........................
1 OR MORE YEARS OF COLLEGE, BUT NO DEGREE.........................
ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR
VOCATIONAL PROGRAM.......................................................................
ASSOCIATE DEGREE: ACADEMIC PROGRAM ....................................
BACHELOR’S DEGREE (e.g., BA, BS)....................................................
05
06
07
08
09
10
11
12
13
14
15
GRADUATE
MASTER’S DEGREE (e.g., MA, MS, MSW, MEng, MBA) ....................... 16
PROFESSIONAL SCHOOL DEGREE (e.g., MD, DDS, DVM, JD)........... 17
DOCTORAL DEGREE (e.g., Ph.D., Ed.D.) .............................................. 18
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–5
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
END LOOP DE01
ASK DE009–DE012 ABOUT SPOUSE OR RESIDENT PARTNER IF
APPLICABLE (RECORD CODED “1” OR “12” IN DE007).
WHEN COMPLETE, CONTINUE WITH NEXT SECTION.
IF NO SPOUSE OR RESIDENT PARTNER (NO RECORD CODED “1” OR “12”
IN DE007, CONTINUE WITH NEXT SECTION.
Appendix A
A.1.3.a–6
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Current Pregnancy Information
CP001. Now I’d like to change the subject and ask some questions about you, your health, and your health history. I’ll
begin by asking about your current pregnancy.
CP002. What was the first day of your last menstrual period?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (CP004)
9--98 (CP004)
CP003. DID RESPONDENT GIVE DATE?
RESPONDENT GAVE COMPLETE DATE ..............................................
INTERVIEWER ENTERED 15 FOR DAY.................................................
1
2
CP004. About how many weeks pregnant were you when you first learned that you were pregnant?
|___|___|
WEEKS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CP005. Since you became pregnant, have you seen a doctor or other health care provider about this pregnancy?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP011)
REFUSED .......................................................................................... 9--97 (CP011)
DON’T KNOW .................................................................................... 9--98 (CP011)
CP006. Is your prenatal provider a family practitioner or internist, an obstetrician/gynecologist, a nurse midwife, or some
other type of provider?
FAMILY PRACTITIONER/INTERNIST ..................................................... 1
OB/GYN ................................................................................................... 2
NURSE MIDWIFE .................................................................................... 3
OTHER PROVIDER (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–7
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
CP007. Has a doctor or other health care provider given you a due date?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP010)
REFUSED .......................................................................................... 9--97 (CP010)
DON’T KNOW .................................................................................... 9--98 (CP010)
CP008. What is that due date?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (CP010)
9--98 (CP010)
CP009. DID RESPONDENT GIVE DATE?
RESPONDENT GAVE COMPLETE DATE ..............................................
INTERVIEWER ENTERED 15 FOR DAY.................................................
1
2
CP010. Since you became pregnant, have you been told by a doctor or other health care provider that you have any of
the following conditions? (Please think only of conditions that you learned of during this pregnancy.)
YES
NO
RF
DK
a.
Diabetes?............................................................................................................
1
2
9--97
9--98
b.
High blood pressure?..........................................................................................
1
2
9--97
9--98
c.
Protein in your urine?..........................................................................................
1
2
9--97
9--98
d.
Preeclampsia or toxemia? ..................................................................................
1
2
9--97
9--98
e.
Early or premature labor? ...................................................................................
1
2
9--97
9--98
f.
Anemia? .............................................................................................................
1
2
9--97
9--98
g.
Rh disease or isoimmunization? .........................................................................
1
2
9--97
9--98
h.
Group B strep? ...................................................................................................
1
2
9--97
9--98
i.
Herpes? ..............................................................................................................
1
2
9--97
9--98
j.
Bacterial Vaginosis? ...........................................................................................
1
2
9--97
9--98
k.
Pelvic inflammatory disease (PID), or infection in your tubes? ...........................
1
2
9--97
9--98
l.
Other sexually transmitted disease or infection, such as chlamydia, syphilis, or
gonorrhea? .........................................................................................................
1
2
9--97
9--98
m.
Any other pregnancy related condition? ............................................................
(SPECIFY):_____________________________________________________
1
2
9--97
9--98
Appendix A
A.1.3.a–8
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
CP011. Where do you plan to deliver your baby:
In a hospital, ............................................................................................. 1
A birthing center, ...................................................................................... 2
At home, or............................................................................................... 3 (CP013)
Some other place? .................................................................................. 4
REFUSED .......................................................................................... 9--97 (CP013)
DON’T KNOW .................................................................................... 9--98 (CP013)
CP012. What is the name and address of this place?
_____________________________________________________
NAME OF BIRTH HOSPITAL/BIRTHING CENTER
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CP013. Since you became pregnant, have you experienced any bleeding other than light spotting, on more than one
occasion?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP015)
REFUSED .......................................................................................... 9--97 (CP015)
DON’T KNOW .................................................................................... 9--98 (CP015)
CP014. Please look at this calendar and tell me when you first had vaginal bleeding?
SHOW CALENDAR.
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CP014A. DID RESPONDENT GIVE DATE?
RESPONDENT GAVE COMPLETE DATE ..............................................
INTERVIEWER ENTERED 15 FOR DAY.................................................
1
2
Appendix A
A.1.3.a–9
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
CP015. Since you became pregnant, have you experienced any nausea or vomiting?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP017)
REFUSED .......................................................................................... 9--97 (CP017)
DON’T KNOW .................................................................................... 9--98 (CP017)
CP016. When did you first experience nausea or vomiting?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CP016A. DID RESPONDENT GIVE DATE?
RESPONDENT GAVE COMPLETE DATE ..............................................
INTERVIEWER ENTERED 15 FOR DAY.................................................
1
2
CP016B. When did you stop experiencing nausea or vomiting?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
STILL EXPERIENCING NAUSEA OR VOMITING .............................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91
9--97
9--98
CP016C. DID RESPONDENT GIVE DATE?
RESPONDENT GAVE COMPLETE DATE ..............................................
INTERVIEWER ENTERED 15 FOR DAY.................................................
1
2
CP016D. When the nausea or vomiting was at its worst, how often did you experience it:
5 or more times a week ............................................................................ 01
2–4 times a week ..................................................................................... 02
Once a week ............................................................................................ 03
1–3 times a month, or............................................................................... 04
Less than once a month? ......................................................................... 05
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–10
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
CP017. Since you became pregnant on how many days have you had a fever over 101 degrees? (IF NEEDED: or 38.3
degrees Celsius?)
|___|___|___|
NUMBER OF DAYS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CP018. Since you became pregnant, have you used a swimming pool?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP020)
REFUSED .......................................................................................... 9--97 (CP020)
DON’T KNOW .................................................................................... 9--98 (CP020)
CP019. How many times did you use a swimming pool?
1–5 times,................................................................................................. 01
6–10 times,............................................................................................... 02
11–20 times, or......................................................................................... 03
More than 20 times?................................................................................. 04
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CP020. (Since you became pregnant, have you used:) A hot tub or whirlpool?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP022)
REFUSED .......................................................................................... 9--97 (CP022)
DON’T KNOW .................................................................................... 9--98 (CP022)
CP021. How many times did you use a hot tub or whirlpool?
1–5 times,................................................................................................. 01
6–10 times,............................................................................................... 02
11–20 times, or......................................................................................... 03
More than 20 times?................................................................................. 04
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CP022. (Since you became pregnant, have you used): A sauna?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP024)
REFUSED .......................................................................................... 9--97 (CP024)
DON’T KNOW .................................................................................... 9--98 (CP024)
Appendix A
A.1.3.a–11
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
CP023. How many times did you use a sauna?
1–5 times,................................................................................................. 01
6–10 times,............................................................................................... 02
11–20 times, or......................................................................................... 03
More than 20 times?................................................................................. 04
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CP024. (Since you became pregnant, have you used:) An electric blanket?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP026)
REFUSED .......................................................................................... 9--97 (CP026)
DON’T KNOW .................................................................................... 9--98 (CP026)
CP025. How many times did you use an electric blanket?
1–5 times,................................................................................................. 01
6–10 times,............................................................................................... 02
11–20 times, or......................................................................................... 03
More than 20 times?................................................................................. 04
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CP026. Did you or your partner go to a doctor or other health care provider to talk about ways to help you become
pregnant this time?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP034)
REFUSED .......................................................................................... 9--97 (CP034)
DON’T KNOW .................................................................................... 9--98 (CP034)
CP027. What types of services or treatments shown on this card did you receive to help you become pregnant with this
pregnancy?
SHOW CARD CP1.
SELECT ALL THAT APPLY.
ADVICE ONLY ......................................................................................... 01
MEDICINES OR SHOTS TO IMPROVE YOUR OVULATION ................ 02
SURGERY TO CORRECT BLOCKED TUBES ........................................ 03
OTHER TYPE OF SURGERY (SPECIFY): _______________________ 04
ARTIFICIAL INSEMINATION ................................................................... 05
IN VITRO FERTILIZATION ..................................................................... 06
OTHER TYPES OF MEDICAL HELP (SPECIFY):__________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–12
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
BOX CP03
CHECK ITEM:
IF CP027F = 06 OR CP027E = 05, CONTINUE WITH CP028.
OTHERWISE GO TO BOX CP05.
CP028. Please tell me who donated the sperm. Was it:
HUSBAND OR PARTNER, ...................................................................... 1
A DONOR, OR ......................................................................................... 2
BOTH YOUR HUSBAND OR PARTNER AND A DONOR? ..................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX CP04
CHECK ITEM:
IF CP027F = 06, CONTINUE WITH CP029.
OTHERWISE GO TO BOX CP05.
CP029. As part of in vitro fertilization, sometimes a donor egg is used.
fertilization?
Was a donor egg used for your in vitro
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP032)
REFUSED .......................................................................................... 9--97 (CP032)
DON’T KNOW .................................................................................... 9--98 (CP032)
CP030. Please tell me who donated the egg. Was it:
A relative that you are biologically related to, ........................................... 1
A relative that you are not biologically related to, .................................... 2
A friend, .................................................................................................... 3
An anonymous donor, or .......................................................................... 4
Some other person? (SPECIFY): _______________________________ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CP032. Sometimes embryos created during in vitro fertilization are frozen so that they can be implanted later on when the
couple is ready to have another baby. Was a previously frozen embryo used to help you become pregnant with
the current pregnancy?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–13
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
BOX CP05
CHECK ITEM:
IF CP027b = 02, CONTINUE WITH CP033.
OTHERWISE GO TO BOX CP06.
CP033. Which of the drugs shown on this card did you use to improve your ovulation for this pregnancy?
SHOW CARD CP3.
SELECT ALL THAT APPLY.
CLOMID ................................................................................................... 01
GONAL F.................................................................................................. 02
BRAVELLE............................................................................................... 03
FOLLISTIM............................................................................................... 04
REPRONEX ............................................................................................. 05
PERGONAL ............................................................................................. 06
PREGNYL ................................................................................................ 07
PROFASI.................................................................................................. 08
NOVAREL ................................................................................................ 09
OTHER DRUG (SPECIFY): ___________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX CP06
CHECK ITEM:
IF CP028 = 2, GO TO EOS.
OTHERWISE, CONTINUE WITH CP034.
CP034. What is the first and last name of your baby’s biological father?
____________________
FIRST NAME
________________________
LAST NAME
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (CP038)
9--98 (EOS)
CP035. Is the biological father of your baby living in this household?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–14
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
CP036. Can the study contact him?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP038)
REFUSED .......................................................................................... 9--97 (CP038)
DON’T KNOW .................................................................................... 9--98 (CP038)
BOX CP07
CHECK ITEM:
IF CP035 = 1, GO TO CP038.
OTHERWISE, CONTINUE WITH CP037.
CP037. What is his home address and phone number?
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CP038. Is this the first pregnancy with this partner?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–15
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Maternal Birth History
MB001. Next, I’d like to ask you about your birth.
MB002. Were you born prematurely, that is more than 3 weeks early?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MB004)
REFUSED .......................................................................................... 9--97 (MB004)
DON’T KNOW .................................................................................... 9--98 (MB004)
MB003. How many weeks early were you born?
|___|___|
WEEKS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
MB004. How much did you weigh when you were born?
|___|___| AND
POUNDS
|___|___| (006)
OUNCES
OR
|___|___|___|___|
GRAMS
(006)
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (MB006)
9--98 (MB005)
MB005. Were you a low birth-weight baby, that is, did you weigh less than 5 pounds 8 ounces (2500 grams) or 5 pounds 8
ounces (2500 grams) at birth?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MB006. When you were born, were you born as a singleton, twin, triplet, or some other multiple birth?
SINGLETON............................................................................................. 1
TWIN ........................................................................................................ 2
TRIPLET................................................................................................... 3
OTHER (SPECIFY): _________________________________________ 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–16
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Maternal Medical History
MC001. Next, I have some general questions about your health.
MC002. Would you say your health in general is . . .
Excellent,.................................................................................................. 1
Very good, ................................................................................................ 2
Good, ....................................................................................................... 3
Fair, or ...................................................................................................... 4
Poor?........................................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC003. Now I’m going to ask you about your physical health, which includes physical illness or injury. During the 30 days
before you became pregnant, on how many days would you say your physical health was not good?
|___|___|
NUMBER OF DAYS
NONE ....................................................................................................... 0
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC004. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how
many days during the 30 days before you became pregnant, would you say your mental health was not good?
|___|___|
NUMBER OF DAYS
NONE ....................................................................................................... 0
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC005. In the 30 days before you became pregnant, for about how many days did poor physical or mental health, keep
you from doing your usual activities such as work, school, recreation, or self-care?
|___|___|
NUMBER OF DAYS
NONE ....................................................................................................... 0
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–17
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MC006. Next are some questions about dental health and gum disease. Gum disease is a common problem. People with
gum disease might have swollen gums, receding gums, sore or infected gums, or loose teeth.
MC007. Do you think you might have gum disease?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC008. Overall, how would you rate the health of your teeth and gums?
Excellent,.................................................................................................. 1
Very good, ................................................................................................ 2
Good, ....................................................................................................... 3
Fair, or ...................................................................................................... 4
Poor?........................................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC009. In the past 12 months, have you had treatment for gum disease such as scaling and root planing, sometimes
called “deep cleaning”? This does not include visits to the dentist just for routine cleanings.
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC010. Have you ever been told by a dental professional that you have lost bone around your teeth?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC011. The next questions are about medical conditions or health problems you might have or may have had.
MC012. Have you ever been told by a doctor or other health care provider that you had asthma?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC013. (Have you ever been told by a doctor or other health care provider that you had:) Eczema or atopic dermatitis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–18
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MC014. (Have you ever been told by a doctor or other health care provider that you had:) Seasonal allergies?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC015. (Have you ever been told by a doctor or other health care provider that you had:) Any other allergies?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC017)
REFUSED .......................................................................................... 9--97 (MC017)
DON’T KNOW .................................................................................... 9--98 (MC017)
MC016. What type of allergy do you have?
SELECT ALL THAT APPLY.
PEANUTS ................................................................................................ 1
BEE STINGS............................................................................................ 2
SHELLFISH.............................................................................................. 3
CATS........................................................................................................ 4
DOGS....................................................................................................... 5
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC017. (Have you ever been told by a doctor or other health care provider that you had:) Hypertension or high blood
pressure when you’re not pregnant?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC018. (Have you ever been told by a doctor or other health care provider that you had:) Diabetes when you’re not
pregnant?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC023)
REFUSED .......................................................................................... 9--97 (MC023)
DON’T KNOW .................................................................................... 9--98 (MC023)
MC019. Have you taken any medicine or received other medical treatment for this in the past 12 months?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–19
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MC020. Have you ever taken insulin?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC023)
REFUSED .......................................................................................... 9--97 (MC023)
DON’T KNOW .................................................................................... 9--98 (MC023)
MC021. Right before you became pregnant this time, were you taking medication by mouth for diabetes?
IF NEEDED: For example, pills
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC022. Right before you became pregnant this time, were you taking Insulin, either by injection or by pump?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC023. (Have you ever been told by a doctor or other health care provider that you had:) High cholesterol?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC024. (Have you ever been told by a doctor or other health care provider that you had:) Ovarian cysts or polycystic
ovarian syndrome (PCOS)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC025. (Have you ever been told by a doctor or other health care provider that you had:) Hypothyroidism, that is, an
under active thyroid?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC027)
REFUSED .......................................................................................... 9--97 (MC027)
DON’T KNOW .................................................................................... 9--98 (MC027)
Appendix A
A.1.3.a–20
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MC026. Have you taken any medicine or received other medical treatment for this in the past 12 months?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC027. (Have you ever been told by a doctor or other health care provider that you had:) Hyperthyroidism, that is, an
overactive thyroid?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC029)
REFUSED .......................................................................................... 9--97 (MC029)
DON’T KNOW .................................................................................... 9--98 (MC029)
MC028. Have you taken any medicine or received other medical treatment for this in the past 12 months?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC029. (Have you ever been told by a doctor or other health care provider that you had:) Anorexia nervosa?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC030. (Have you ever been told by a doctor or other health care provider that you had:) Bulimia?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC031. (Have you ever been told by a doctor or other health care provider that you had:) Any type of cancer?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC033)
REFUSED .......................................................................................... 9--97 (MC033)
DON’T KNOW .................................................................................... 9--98 (MC033)
Appendix A
A.1.3.a–21
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MC032. What type or types of cancer were you diagnosed with?
SELECT ALL THAT APPLY.
BRAIN ...................................................................................................... 1
BREAST ................................................................................................... 2
CERVICAL ............................................................................................... 3
COLON..................................................................................................... 4
HODGKIN’S LYMPHOMA ........................................................................ 5
LEUKEMIA ............................................................................................... 6
LIVER ....................................................................................................... 7
LUNG ....................................................................................................... 8
NON-HODGKIN’S LYMPHOMA............................................................... 9
OVARIAN ................................................................................................. 10
SKIN ......................................................................................................... 11
THYROID ................................................................................................. 12
UTERINE.................................................................................................. 13
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC033. (Have you ever been told by a doctor or other health care provider that you had:) Sickle cell anemia or sickle cell
trait?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC035)
REFUSED .......................................................................................... 9--97 (MC035)
DON’T KNOW .................................................................................... 9--98 (MC035)
MC034. Which do you have?
SICKLE CELL ANEMIA ............................................................................ 1
SICKLE CELL TRAIT ............................................................................... 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC035. (Have you ever been told by a doctor or other health care provider that you had:) An autoimmune disorder such
as rheumatoid arthritis, lupus, or scleroderma?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC037)
REFUSED .......................................................................................... 9--97 (MC037)
DON’T KNOW .................................................................................... 9--98 (MC037)
Appendix A
A.1.3.a–22
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MC036. What type of autoimmune disorder were you diagnosed with?
RHEUMATOID ARTHRITIS ..................................................................... 01
LUPUS ..................................................................................................... 02
SCLERODERMA...................................................................................... 03
MULTIPLE SCLEROSIS .......................................................................... 04
GRAVES’ DISEASE ................................................................................. 05
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC037. (Have you ever been told by a doctor or other health care provider that you had:) Migraines?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC038. (Have you ever been told by a doctor or other health care provider that you had:) Epilepsy or seizures?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC039. (Have you ever been told by a doctor or other health care provider that you had:) Sleep apnea?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC040. (Have you ever been told by a doctor or other health care provider that you had:) Blindness or any severe vision
impairment?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC041. (Have you ever been told by a doctor or other health care provider that you had:) Deafness or any severe hearing
impairment?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–23
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MC042. (Have you ever been told by a doctor or other health care provider that you had:) Attention deficit disorder (ADD)
or attention deficit hyperactivity disorder (ADHD)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC043. (Have you ever been told by a doctor or other health care provider that you had:) Autism, Asperger syndrome, or
any other autism spectrum disorder?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC044. (Have you ever been told by a doctor or other health care provider that you had:) Bipolar disorder?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC045. (Have you ever been told by a doctor or other health care provider that you had:) Depression, other than bipolar
disorder?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC046. (Have you ever been told by a doctor or other health care provider that you had:) An anxiety disorder, such as
generalized anxiety disorder or obsessive compulsive disorder (OCD)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC047)
REFUSED .......................................................................................... 9--97 (MC047)
DON’T KNOW .................................................................................... 9--98 (MC047)
MC047. What type of anxiety disorder were you diagnosed with?
SELECT ALL THAT APPLY.
GENERALIZED ANXIETY DISORDER .................................................... 01
OBSESSIVE COMPULSIVE DISORDER................................................. 02
SOCIAL PHOBIA...................................................................................... 03
SPECIFIC PHOBIA .................................................................................. 04
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–24
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MC048. (Have you ever been told by a doctor or other health care provider that you had:) HIV or AIDS?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC049. (Have you ever been told by a doctor or other health care provider that you had:) Hepatitis B?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC050. (Have you ever been told by a doctor or other health care provider that you had:) Any other chronic or long lasting
conditions?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
MC051. What other chronic condition or conditions were you diagnosed with?
___________________________
OTHER CONDITION
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.a–25
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Health Behaviors Part 1
HB001. The following questions are about your sleep habits during the past 7 days.
HB002. Thinking of the past 7 days, on a typical day, how much time did you sleep at night?
|___|___|
HOURS
|___|___|
MINUTES
Less than 4 hours,.................................................................................... 1
4–5 hours, ................................................................................................ 2
6–7 hours, ................................................................................................ 3
8–9 hours, or ............................................................................................ 4
10 or more hours? .................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB003. During the past 7 days, on a typical day, how much additional time did you sleep during the day?
|___|___|
HOURS
|___|___|
MINUTES
Not at all, .................................................................................................. 1
Less than 1 hour,...................................................................................... 2
1–2 hours, or ............................................................................................ 3
More than 2 hours? .................................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB004. Next, I’m going to ask about the time you spent being physically active in the last 7 days.
Please answer each question even if you do not consider yourself to be an active person. Think about the
activities you do at work, as part of your house or yard work, to get from place to place, and in your spare time for
recreation, exercise, or sport.
Now, think about all the vigorous activities which take hard physical effort that you did in the last 7 days.
Vigorous activities make you breathe much harder than normal and may include heavy lifting, digging, aerobics,
or fast bicycling. Think only about those activities that you did during the last 7 days for at least 10 minutes at a
time.
HB005. During the last 7 days, on how many days did you do vigorous physical activities?
|___|
NUMBER OF DAYS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (HB008)
9--98 (HB008)
Appendix A
A.1.3.a–26
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
BOX HB01
CHECK ITEM:
IF HB005 = 0, GO TO HB008.
OTHERWISE, CONTINUE WITH HB006.
HB006. On average, how much time did you usually spend doing vigorous physical activities on each of those days?
PROBE: IF RESPONDENT GIVES AN ANSWER THAT IS LESS THAN 10 MINUTES: “Please think only of
activities that you have done for at least 10 minutes at a time.”
|___|___|
HOURS
|___|___| (HB008)
MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (HB008)
9--98
HB007. How much time in total did you spend over the last 7 days doing vigorous physical activities?
|___|___|
HOURS
|___|___|
MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
HB008. Now think about activities which take moderate physical effort that you did in the last 7 days. Moderate physical
activities make you breathe somewhat harder than normal and may include carrying light loads, bicycling at a
regular pace, or doubles tennis. Do not include walking. Again, think about only those physical activities that you
did for at least 10 minutes at a time.
HB009. During the last 7 days, on how many days did you do moderate physical activities?
|___|
NUMBER OF DAYS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
BOX HB02
CHECK ITEM:
IF HB009 = 0, GO TO HB012.
OTHERWISE, CONTINUE WITH HB010.
9--97 (HB012)
9--98 (HB012)
Appendix A
A.1.3.a–27
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
HB010. On average, how much time did you usually spend doing moderate physical activities on each of those days?
PROBE: IF RESPONDENT GIVES AN ANSWER THAT IS LESS THAN 10 MINUTES: “Please think only of
activities that you have done for at least 10 minutes at a time.”
|___|___|
HOURS
|___|___| (HB012)
MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (HB012)
9--98
HB011. What is the total amount of time you spent over the last 7 days doing moderate physical activities?
|___|___|
HOURS
|___|___|
MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
HB012. Now think about the time you spent walking in the last 7 days. This includes at work and at home, walking to
travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or
leisure.
HB013. During the last 7 days, on how many days did you walk for at least 10 minutes at a time?
|___|
NUMBER OF DAYS PER WEEK
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (HB016)
9--98 (HB016)
BOX HB03
CHECK ITEM:
IF HB013 = 0, GO TO HB016.
OTHERWISE, CONTINUE WITH HB014.
HB014. On average, how much time did you usually spend walking on each of those days?
PROBE: IF RESPONDENT GIVES AN ANSWER THAT IS LESS THAN 10 MINUTES: “Please think only of
activities that you have done for at least 10 minutes at a time.”
|___|___|
HOURS
|___|___| (HB016)
MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (HB016)
9--98
Appendix A
A.1.3.a–28
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
HB015. What is the total amount of time you spent walking over the last 7 days?
|___|___|
HOURS
|___|___|
MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
HB016. Overall, how would you say your activity level has changed since you found out you were pregnant? Has it…
Stayed the same as before you were pregnant, ....................................... 1
Increased a lot,......................................................................................... 2
Increased a little, ...................................................................................... 3
Decreased a little, or ................................................................................ 4
Decreased a lot? ...................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB017. Now I’d like to change topics and ask you some questions about drinking beverages with caffeine.
HB018. In the 3 months before you knew you were pregnant, did you drink:
IF YES: How many of these drinks did you have per day?
INTERVIEWER INSTRUCTION:
IF ANSWER IS “NO” WRITE IN “0” FOR HOW MANY PER DAY.
IF RESPONDENT DRINKS LESS THAN 1 DRINK PER DAY, WRITE IN “0” FOR HOW MANY PER DAY.
a.
b.
c.
d.
Caffeinated coffee? ..................................................................
Caffeinated tea? .......................................................................
Soda with caffeine (Coke, Pepsi, Dr. Pepper, Mountain Dew)?
Energy drinks with caffeine (Red Bull, Amp)? ..........................
YES
NO
1
1
1
1
2
2
2
2
HOW MANY
PER DAY
RF
|___|___|
|___|___|
|___|___|
|___|___|
9--97
9--97
9--97
9--97
DK
9--98
9--98
9--98
9--98
HB019. Currently, do you drink:
IF YES: How many of these drinks do you have per day?
INTERVIEWER INSTRUCTION:
IF ANSWER IS “NO” WRITE IN “0” FOR HOW MANY PER DAY.
IF RESPONDENT DRINKS LESS THAN 1 DRINK PER DAY, WRITE IN “0” FOR HOW MANY PER DAY.
a.
b.
c.
d.
Caffeinated coffee? ..................................................................
Caffeinated tea? .......................................................................
Soda with caffeine (Coke, Pepsi, Dr. Pepper, Mountain Dew)?
Energy drinks with caffeine (Red Bull, Amp)? ..........................
YES
NO
1
1
1
1
2
2
2
2
HOW MANY
PER DAY
RF
|___|___|
|___|___|
|___|___|
|___|___|
9--97
9--97
9--97
9--97
DK
9--98
9--98
9--98
9--98
Appendix A
A.1.3.a–29
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Use of Medicines, Supplements and Alternative Medicines
UM001. The next questions are about your use of prescription medications, over-the-counter medications, and dietary
supplements.
UM002. Since you became pregnant, have you used or taken medication for which a prescription is needed? Include only
those products prescribed by a health professional such as a doctor or dentist. Please include prescription
vitamins or minerals.
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM003. Since you became pregnant, have you used or taken any over-the-counter or nonprescription medications, or any
nonprescription vitamins, minerals, herbals, or other dietary supplements? This card lists some examples of
different types of over-the-counter medications, vitamins, minerals, and dietary supplements.
SHOW CARD UM1.
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX UM01
CHECK ITEM:
IF UM002 OR UM003, = “1,” CONTINUE WITH UM004.
OTHERWISE, GO TO EOS.
UM004. May I please see the containers for all the {prescriptions,} {and} {non-prescription medicines and supplements},
that you used or took since you became pregnant?
RESPONDENT HAS CONTAINERS........................................................
RESPONDENT DOES NOT HAVE CONTAINERS..................................
DISPLAY INSTRUCTIONS:
IF UM002 AND UM003 = 1, DISPLAY “{and}”.
IF UM002 = “1” DISPLAY “{prescription medicines,}”.
IF UM003 = “1” DISPLAY “{and non-prescription medicines and supplements}”.
BOX UM02
CHECK ITEM:
IF UM002 = “1”, CONTINUE WITH UM005.
OTHERWISE, GO TO BOX UM03.
1
2
Appendix A
A.1.3.a –30
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
UM005. I will start with the prescription medications. {Please show me any you have taken since you became pregnant/
Please tell me the names of the prescription medications and supplements that you have taken since you became
pregnant}.
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER.
ACTIVATE LOOKUP AND SELECT MEDICATIONS FROM LIST. IF A MEDICATION IS NOT ON LIST, ENTER
THE FULL NAME (INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
PRODUCT ON PRESCRIPTION MEDICINE LIST .................................. 1
PRODUCT NOT ON LIST (SPECIFY): __________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DISPLAY INSTRUCTION:
IF UM004 = “1,” DISPLAY “{Please show me any you have taken since you became pregnant}.”
IF UM004 = “2,” DISPLAY “{Please tell me the names of the prescription medications and supplements that you
have taken since you became pregnant}.”
BEGIN LOOP UM01
LOOP:
CYCLE THROUGH UM006–UM011 FOR EACH PRESCRIPTION.
UM006. Let’s talk about {MEDICATION}.
UM007. PRODUCT LABEL SEEN?
YES ..........................................................................................................
NO ............................................................................................................
1
2
UM008. RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK:
How is the {MEDICATION} taken?
By mouth, ................................................................................................ 01
Inhaled either by mouth or nose, .............................................................. 02
Injected,.................................................................................................... 03
Applied to the skin, such as a patch or creams, or ................................... 04
Some other way? (SPECIFY): _________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM009. When did you start taking {MEDICATION}?
Before you became pregnant, .................................................................. 1
In your first month of pregnancy, or.......................................................... 2
After your first month of pregnancy? ........................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a –31
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
UM010. Are you still taking {MEDICATION}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM011. How often {do/did} you use or take {MEDICATION}?
|___|___|
ENTER NUMBER
ENTER UNIT
PER DAY.................................................................................................. 1
PER WEEK .............................................................................................. 2
PER MONTH............................................................................................ 3
PER YEAR ............................................................................................... 4
AS NEEDED....................................................................................... 9--95
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP UM01
LOOP:
CYCLE THROUGH UM006 – UM011 FOR THE NEXT PRESCRIPTION
MEDICATION IN ROSTER.
WHEN FINISHED WITH ALL MEDICATIONS LISTED IN ROSTER CONTINUE
WITH BOX UM03.
BOX UM03
CHECK ITEM:
IF UM003 = “1,” CONTINUE WITH UM012.
OTHERWISE, GO TO EOS.
Appendix A
A.1.3.a –32
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
UM012. Now let’s talk about your use of over-the-counter medications, and nonprescription vitamins, minerals,
herbals, and other dietary supplements. {Please show me any you have taken since you became
pregnant/Please tell me the names of the nonprescription medications and nonprescription vitamins, minerals,
herbals, and supplements that you have taken since you became pregnant}
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER.
ACTIVATE LOOKUP AND SELECT PRODUCT FROM LIST. IF PRODUCT NOT ON LIST, ENTER THE FULL
NAME (INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
SHOW CARD UM1.
PRODUCT ON MEDICINE LIST .............................................................. 1
PRODUCT NOT ON LIST (SPECIFY): __________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DISPLAY INSTRUCTION:
IF UM004 = “1”, DISPLAY “{Please show me any you have taken since you became pregnant}”.
IF UM004 = “2”, DISPLAY “{Please tell me the names of the nonprescription medications and nonprescription
vitamins, minerals, herbals, and supplements that you have taken since you became pregnant}”.
BEGIN LOOP UM02
LOOP:
CYCLE THROUGH UM013 – UM018 FOR EACH OTC.
UM013. Let’s talk about {PRODUCT}.
UM014. WAS PRODUCT LABEL SEEN?
YES ..........................................................................................................
NO ............................................................................................................
1
2
UM015. RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK:
How is this {PRODUCT} taken?
By mouth, ................................................................................................ 01
Inhaled either by mouth or nose, .............................................................. 02
Injected,.................................................................................................... 03
Applied to the skin, such as a patch or creams, or ................................... 04
Some other way? (SPECIFY): _________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a –33
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
UM016. When did you start taking {PRODUCT}?
Before you became pregnant, .................................................................. 1
In your first month of pregnancy, or.......................................................... 2
After your first month of pregnancy? ........................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM017. Since you became pregnant, how often have you taken {PRODUCT}?
Less than once a month, .......................................................................... 01
Once a month,.......................................................................................... 02
2-3 times a month (but less than once a week), ....................................... 03
1-2 times a week, ..................................................................................... 04
3-4 times a week, ..................................................................................... 05
5-6 times a week, or ................................................................................. 06
Every day? ............................................................................................... 07
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM018. Are you still taking {PRODUCT}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP UM02
LOOP:
CYCLE THROUGH UM013–UM018 FOR THE NEXT OTC IN ROSTER.
WHEN FINISHED WITH ALL OTCS LISTED IN ROSTER CONTINUE WITH
NEXT SECTION.
Appendix A
A.1.3.a–34
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Doctor Visits and Hospitalizations
DV001. I am now going to ask some questions about visits to a doctor or other health care provider. Please include
routine prenatal visits, visits for sonograms or ultrasounds, an amniocentesis, and other pregnancy related tests
and procedures, as well as any other visits to a doctor or other health care provider at a clinic, doctor’s office or
HMO, emergency room, or hospital outpatient department. Please refer to any personal record or calendar that
you keep that would help you to remember the dates of these visits. If you have this information available, please
go and get it now.
BOX DV00
CHECK ITEM:
IF CP005 = 1, GO TO BEGIN LOOP DV01.
OTHERWISE, CONTINUE WITH DV002.
DV002. Since you became pregnant, have you seen a doctor or heath care provider for any reason?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
BEGIN LOOP DV01
LOOP:
CYCLE THROUGH DV003–DV016 FOR EACH VISIT TO A DOCTOR OR
OTHER HEALTH CARE PROVIDER.
DV003. {Beginning with the most recent visit, please give me the date of the visit. Please give me the date of the next
most recent visit.}
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
IF FIRST CYCLE, DISPLAY “{Beginning with the most recent visit, please give me the date of the visit. Please
refer to any personal record or calendar that you keep that would help you to remember the dates of these
visits.}”. ON SUBSEQUENT CYCLES, DISPLAY “{Please give me the date of the next most recent visit.}.”
Appendix A
A.1.3.a–35
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DV004. What kind of place did you go to—a clinic or health center, doctor’s office or HMO, a hospital emergency room, a
hospital outpatient department, or some other place?
CLINIC OR HEALTH CENTER ................................................................ 1
DOCTOR’S OFFICE OR HMO................................................................. 2
HOSPITAL EMERGENCY ROOM ........................................................... 3
HOSPITAL OUTPATIENT DEPARTMENT .............................................. 4
SOME OTHER PLACE (SPECIFY):_____________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DV005. What was the main reason for the visit?
Prenatal care (including sonograms, amniocentesis, or other
pregnancy related procedures),............................................................. 1
Physical, .................................................................................................. 2
Sick visit, or .............................................................................................. 3
Some other reason? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(DV012)
(DV012)
(DV012)
(DV012)
(DV012)
DV006. At this visit, what was your weight?
WEIGHT MEASURED..............................................................................
WEIGHT NOT MEASURED .....................................................................
1
2 (DV008)
DV007. (At this visit, what was your weight?)
|___|___|___|.|___|
WEIGHT
POUNDS ..................................................................................................
KILOGRAMS ............................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
DV008. At this visit, what was your blood pressure?
BLOOD PRESSURE MEASURED...........................................................
BLOOD PRESSURE NOT MEASURED ..................................................
1
2 (DV011)
Appendix A
A.1.3.a–36
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DV009. (At this visit, what was your blood pressure?)
|___|___|___|
SYSTOLIC BLOOD PRESSURE
|___|___|___|
DIASTOLIC BLOOD PRESSURE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX DV02
CHECK ITEM:
IF DV009 = “9-97” OR “9-98,” CONTINUE WITH DV010.
OTHERWISE, GO TO DV011.
DV010. Was it normal, high or low?
NORMAL .................................................................................................. 1
HIGH ........................................................................................................ 2
LOW ......................................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DV011. At this visit, were any of the following procedures performed?
a.
b.
c.
d.
Ultrasound or sonogram? ...................................................................
Amniocentesis? ..................................................................................
CVS (Chorionic Villus Sampling)? ......................................................
Any other test or procedure? (SPECIFY): _____________________
YES
NO
RF
DK
1
1
1
1
2
2
2
2
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
BOX DV03
CHECK ITEM:
IF DV005 = “1,” GO TO DV016.
OTHERWISE, CONTINUE WITH DV012.
DV012. Did a doctor or other health care provider give you a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DV014)
REFUSED .......................................................................................... 9--97 (DV014)
DON’T KNOW .................................................................................... 9--98 (DV014)
Appendix A
A.1.3.a–37
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DV013. What was the diagnosis?
SELECT ALL THAT APPLY.
ANEMIA.................................................................................................... 01
BACTERIAL VAGINOSIS......................................................................... 02
EARLY OR PREMATURE LABOR........................................................... 03
GESTATIONAL DIABETES...................................................................... 04
GROUP B STREP .................................................................................... 05
HERPES................................................................................................... 06
HIGH BLOOD PRESSURE ...................................................................... 07
ISOIMMUNIZATION................................................................................. 08
PELVIC INFLAMMATORY DISEASE (PID) ............................................. 09
PREECLAMPSIA ..................................................................................... 10
PROTEIN IN YOUR URINE ..................................................................... 11
RH DISEASE............................................................................................ 12
TOXEMIA ................................................................................................. 13
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DV014. Did you receive any vaccinations at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DV016)
REFUSED .......................................................................................... 9--97 (DV016)
DON’T KNOW .................................................................................... 9--98 (DV016)
DV015. What did you receive?
SELECT ALL THAT APPLY.
FLU/INFLUENZA......................................................................................
HEPATITIS B ...........................................................................................
TETANUS/DIPHTHERIA ..........................................................................
MENINGOCOCCAL .................................................................................
OTHER (SPECIFY): _________________________________________
REFUSED ................................................................................................
DON’T KNOW ..........................................................................................
1
2
3
4
6
7
8
DV016. Have you had any other visits to a doctor or other health care provider since you became pregnant? Please
include routine prenatal visits, as well as visits to a doctor or other health care provider either at a clinic, doctor’s
office or HMO, emergency room, or outpatient department for any other reason.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_DV01)
REFUSED .......................................................................................... 9--97 (EL_DV01)
DON’T KNOW .................................................................................... 9--98 (EL_DV01)
Appendix A
A.1.3.a–38
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
END LOOP DV01
LOOP:
IF DV016 = “1,” CYCLE AGAIN.
OTHERWISE, END LOOP AND CONTINUE WITH DV017.
DV017. Since you became pregnant, have you spent at least one night in the hospital?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX DV04)
REFUSED .......................................................................................... 9--97 (BOX DV04)
DON’T KNOW .................................................................................... 9--98 (BOX DV04)
BEGIN LOOP DV02
LOOP:
CYCLE THROUGH DV018–DV024 FOR EACH HOSPITALIZATION.
DV018. What was the admission date of your {next} most recent hospitalization?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DISPLAY INSTRUCTION:
IF OTHER THAN FIRST CYCLE, DISPLAY “{next}”.
DV019. How many nights did you stay at the hospital during this hospitalization?
|___|___|___|
NUMBER OF NIGHTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DV020. Did a doctor or other health care provider give you a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DV022)
REFUSED .......................................................................................... 9--97 (DV022)
DON’T KNOW .................................................................................... 9--98 (DV022)
Appendix A
A.1.3.a–39
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DV021. What was the diagnosis?
SELECT ALL THAT APPLY.
DEHYDRATION ....................................................................................... 01
PRETERM LABOR................................................................................... 02
HYPEREMISIS......................................................................................... 03
PREECLAMPSIA ..................................................................................... 04
RUPTURE OF MEMBRANES .................................................................. 05
KIDNEY DISORDER ................................................................................ 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DV022. Did you receive any treatments? Please include any vaccinations you may have received.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DV024)
REFUSED .......................................................................................... 9--97 (DV024)
DON’T KNOW .................................................................................... 9--98 (DV022)
DV023. What treatments did you receive?
_____________________________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DV024. Have you had any other hospitalizations since you became pregnant?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP DV02
LOOP:
IF DV024 = “1,” CYCLE AGAIN.
OTHERWISE, CONTINUE WITH BOX DV04.
BOX DV04
CHECK ITEM:
IF ANY RECORD OF DV011A = “1,” THEN GO TO EOS.
OTHERWISE, CONTINUE WITH DV025.
Appendix A
A.1.3.a–40
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DV025. Part of the National Children’s Study includes an early sonogram or ultrasound to help determine the exact age of
your baby.
DV026. Do you have a sonogram or ultrasound scheduled?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
DV027. What is the date of your sonogram or ultrasound appointment?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.a–41
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Housing Characteristics
HC001. Now I’d like to change the subject and find out more about your home and the area in which you live.
HC002. Is your home…
Owned or being bought by you or someone in your household,............... 1
Rented, or................................................................................................. 2
Occupied without payment of rent? .......................................................... 3
Some other arrangement (SPECIFY): ___________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC003. In what year was your home (or building) built?
|___|___|___|___| (HC005)
YEAR OF CONSTRUCTION
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
HC004. Can you tell us, which of these categories do you think best describes when your home or building was built?
SHOW CARD HC1.
2001 TO PRESENT ................................................................................. 01
1981 TO 2000 .......................................................................................... 02
1961 TO 1980 .......................................................................................... 03
1941 TO 1960 .......................................................................................... 04
1940 OR BEFORE ................................................................................... 05
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC005. How long have you lived in this home?
|___|___|
NUMBER
WEEKS ....................................................................................................
MONTHS..................................................................................................
YEARS .....................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
9--97
9--98
Appendix A
A.1.3.a–42
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
HC006. Now I’m going to ask about how your home is heated and cooled.
HC007. Which of these types of heat sources best describes the main heating fuel source for your home?
SHOW CARD HC2.
ELECTRIC................................................................................................ 01
GAS – PROPANE OR LP ........................................................................ 02
OIL ........................................................................................................... 03
WOOD...................................................................................................... 04
KEROSENE OR DIESEL ......................................................................... 05
COAL OR COKE ...................................................................................... 06
SOLAR ENERGY ..................................................................................... 07
HEAT PUMP (GEOTHERMAL) ................................................................ 08
NO HEATING SOURCE........................................................................... 09 (HC011)
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC008. Are there any other types of heat you use regularly during the heating season to heat your home?
SHOW CARD HC2.
SELECT ALL THAT APPLY.
ELECTRIC................................................................................................ 01
GAS – PROPANE OR LP......................................................................... 02
OIL ........................................................................................................... 03
WOOD...................................................................................................... 04
KEROSENE OR DIESEL ......................................................................... 05
COAL OR COKE ...................................................................................... 06
SOLAR ENERGY ..................................................................................... 07
HEAT PUMP (GEOTHERMAL) ................................................................ 08
NO OTHER HEATING SOURCE ............................................................. 09
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–43
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
HC009. During which month do you usually start using any type of heat in your home?
JANUARY................................................................................................. 01
FEBRUARY.............................................................................................. 02
MARCH .................................................................................................... 03
APRIL ....................................................................................................... 04
MAY ......................................................................................................... 05
JUNE ........................................................................................................ 06
JULY ........................................................................................................ 07
AUGUST .................................................................................................. 08
SEPTEMBER ........................................................................................... 09
OCTOBER................................................................................................ 10
NOVEMBER............................................................................................. 11
DECEMBER ............................................................................................. 12
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC010. During which month do you usually stop using all types of heat in your home?
JANUARY................................................................................................. 01
FEBRUARY.............................................................................................. 02
MARCH .................................................................................................... 03
APRIL ....................................................................................................... 04
MAY ......................................................................................................... 05
JUNE ........................................................................................................ 06
JULY ........................................................................................................ 07
AUGUST .................................................................................................. 08
SEPTEMBER ........................................................................................... 09
OCTOBER................................................................................................ 10
NOVEMBER............................................................................................. 11
DECEMBER ............................................................................................. 12
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC011. Does your home have any type of cooling or air conditioning?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX HC01)
REFUSED .......................................................................................... 9--97 (BOX HC01)
DON’T KNOW .................................................................................... 9--98 (BOX HC01)
Appendix A
A.1.3.a–44
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
HC012. Which of the following kinds of cooling systems do you regularly use?
SELECT ALL THAT APPLY.
Window or wall air conditioners, ............................................................... 01
Central air conditioning,............................................................................ 02
Evaporative cooler (swamp cooler), or ..................................................... 03
Fans ......................................................................................................... 04
NO COOLING OR AIR CONDITIONING REGULARLY USED ................ 05 (HC015)
Some other cooling system (SPECIFY): _________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC013. During which month do you usually start using any type of cooling or air conditioning in your home?
JANUARY................................................................................................. 01
FEBRUARY.............................................................................................. 02
MARCH .................................................................................................... 03
APRIL ....................................................................................................... 04
MAY ......................................................................................................... 05
JUNE ........................................................................................................ 06
JULY ........................................................................................................ 07
AUGUST .................................................................................................. 08
SEPTEMBER ........................................................................................... 09
OCTOBER................................................................................................ 10
NOVEMBER............................................................................................. 11
DECEMBER ............................................................................................. 12
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC014. During which month do you usually stop using all types of cooling or air conditioning in your home?
JANUARY................................................................................................. 01
FEBRUARY.............................................................................................. 02
MARCH .................................................................................................... 03
APRIL ....................................................................................................... 04
MAY ......................................................................................................... 05
JUNE ........................................................................................................ 06
JULY ........................................................................................................ 07
AUGUST .................................................................................................. 08
SEPTEMBER ........................................................................................... 09
OCTOBER................................................................................................ 10
NOVEMBER............................................................................................. 11
DECEMBER ............................................................................................. 12
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX HC01
IF HC007 = “09” AND HC011 = “2,” GO TO HC016.
OTHERWISE, CONTINUE WITH HC015.
Appendix A
A.1.3.a–45
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
HC015. Does your furnace or air conditioning system use a special HEPA (High Efficiency Particulate Air) or other special
allergy filter to filter the air?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC016. Thinking about the past 7 days, approximately how many hours a day did you keep the windows or doors open in
your home (for ventilation or to let air in)? Was it…
Less than 1 hour per day,......................................................................... 1
1–3 hours per day, ................................................................................... 2
4–12 hours per day, ................................................................................. 3
More than 12 hours per day, or ................................................................ 4
Not at all? ................................................................................................. 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC017. Water damage is a common problem that occurs inside of many homes. Water damage includes water stains on
the ceiling or walls, rotting wood, and flaking sheetrock or plaster. This damage may be from broken pipes, a
leaky roof, or floods.
HC018. In the past 12 months, have you seen any water damage inside your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC019. In the past 12 months, have you seen any mold or mildew on walls or other surfaces other than the shower or
bathtub, inside your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (HC021)
REFUSED .......................................................................................... 9--97 (HC021)
DON’T KNOW .................................................................................... 9--98 (HC021)
Appendix A
A.1.3.a–46
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
HC020. In which rooms have you seen the mold or mildew?
PROBE: Any other rooms?
SELECT ALL THAT APPLY.
KITCHEN.................................................................................................. 01
LIVING ROOM ......................................................................................... 02
HALL/LANDING ....................................................................................... 03
RESPONDENT’S BEDROOM.................................................................. 04
OTHER BEDROOM ................................................................................. 05
BATHROOM/TOILET ............................................................................... 06
BASEMENT.............................................................................................. 07
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC021. The next few questions ask about any recent additions or renovations to your home.
HC022. Since you became pregnant, have any additions been built onto your home to make it bigger?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC023. Since you became pregnant, have any renovations or other construction been done in your home? Include only
major projects. Do not count smaller projects that were just painting or wall papering.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (HC025)
REFUSED .......................................................................................... 9--97 (HC025)
DON’T KNOW .................................................................................... 9--98 (HC025)
HC024. Which rooms were renovated?
PROBE: Any others?
SELECT ALL THAT APPLY.
KITCHEN.................................................................................................. 01
LIVING ROOM ......................................................................................... 02
HALL/LANDING ....................................................................................... 03
RESPONDENT’S BEDROOM.................................................................. 04
OTHER BEDROOM ................................................................................. 05
BATHROOM/TOILET ............................................................................... 06
BASEMENT.............................................................................................. 07
OTHER (SPECIFY): _________________________________________ 08
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–47
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
HC025. Next, I am going to ask about appliances in your home.
HC026. Do you have a clothes dryer inside your home or apartment?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (HC029)
REFUSED .......................................................................................... 9--97 (HC029)
DON’T KNOW .................................................................................... 9--98 (HC029)
HC027. What kind of clothes dryer do you have? Is it:
Electric, or ................................................................................................ 1
Gas?......................................................................................................... 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC028. Does the clothes dryer have a vent that blows the air outdoors?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC029. Is a gas stove or oven used for cooking or baking in your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (HC031)
REFUSED .......................................................................................... 9--97 (HC031)
DON’T KNOW .................................................................................... 9--98 (HC031)
HC030. Is this gas stove or oven used for more than an hour at a time on 2 or more days per week?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC031. How many hours per week is a laser printer or laser photocopier used inside your home? Do not include ink jet
printers or photocopiers. Would you say…
None,........................................................................................................ 1
Less than one hour per week, .................................................................. 2
1–3 hours per week, ................................................................................. 3
4–20 hours per week, or........................................................................... 4
More than 20 hours per week?................................................................. 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–48
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
HC032. How many hours per week is an ozone generator or portable air cleaner used inside your home? Would you
say…
None,........................................................................................................ 1
Less than one hour per week, .................................................................. 2
1–3 hours per week, ................................................................................. 3
4–20 hours per week, or........................................................................... 4
More than 20 hours per week?................................................................. 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC033. Now I’d like to ask about the water in your home.
HC034. What water source in your home do you use most of the time for drinking:
Tap water, ................................................................................................ 1
Filtered tap water,..................................................................................... 2
Bottled water, or ....................................................................................... 3
Some other source? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC035. What water source in your home is used most of the time for cooking:
Tap water, ................................................................................................ 1
Filtered tap water,..................................................................................... 2
Bottled water, or ....................................................................................... 3
Some other source? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC036. Now, a couple of questions about your neighborhood.
HC037. In your opinion, is your neighborhood…
A very good place to live, ......................................................................... 1
A fairly good place to live,......................................................................... 2
Not a very good place to live, or ............................................................... 3
Not at all a good place to live? ................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC038. Do you feel that your neighborhood is…
Very safe, ................................................................................................. 1
Somewhat safe,........................................................................................ 2
Somewhat unsafe, or ............................................................................... 3
Very unsafe? ............................................................................................ 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–49
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Product Use
PR001. These questions ask about some different types of products you may have used to take care of yourself, your
family, or your home. Please choose your answer from one of these categories.
SHOW CARD PR1.
PR002. Since you became pregnant, how often have you used the following types of products:
SHOW CARD PR1.
A
LESS
FEW ABOUT
1–3
THAN
TIMES ONCE TIMES
ONCE NOT
EVERY
A
A
A
A
AT
DAY WEEK WEEK MONTH MONTH ALL
a. Bleach?.................................................
b. Disinfectants other than bleach, such
as Lysol? ..............................................
c. Window or glass cleaner?.....................
d. Carpet cleaner? ....................................
e. Any type of air fresheners including
spray, stick, aerosol, or plug-in? ...........
f. Other aerosols or sprays of any kind,
including hair spray?.............................
g. Paint or varnish?...................................
h. Turpentine, mineral spirits, or paint
thinner?.................................................
i. Other types of paint stripper? ...............
RF
DK
01
02
03
04
05
06 9--97 9--98
01
01
01
02
02
02
03
03
03
04
04
04
05
05
05
06 9--97 9--98
06 9--97 9--98
06 9--97 9--98
01
02
03
04
05
06 9--97 9--98
01
01
02
02
03
03
04
04
05
05
06 9--97 9--98
06 9--97 9--98
01
01
02
02
03
03
04
04
05
05
06 9--97 9--98
06 9--97 9--98
PR003. Since you became pregnant, about how often have candles or incense been burned inside your home?
Every day, ................................................................................................ 01
A few times a week, ................................................................................. 02
About once a week, .................................................................................. 03
1–3 times a month, .................................................................................. 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR004. Since you became pregnant, were the personal products that you have used, such as lotions, gels, creams,
shampoos, or soaps, usually scented, unscented, or did you use both scented and unscented products?
SCENTED ................................................................................................ 1
UNSCENTED ........................................................................................... 2
USE BOTH SCENTED AND UNSCENTED PRODUCTS ........................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–50
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
PR005. Since you became pregnant, about how often have you, or anyone in your household, used scented products for
your home such as scented laundry detergents, fabric softener, or dish soaps? Do not include air fresheners,
candles, or incense.
Every day, ................................................................................................ 01
A few times a week, ................................................................................. 02
About once a week, .................................................................................. 03
1–3 times a month, .................................................................................. 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR006. Since you became pregnant, have you used any insect repellent such as spray, lotion, or towelettes on yourself or
someone else?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PR009)
REFUSED .......................................................................................... 9--97 (PR009)
DON’T KNOW .................................................................................... 9--98 (PR009)
PR007. Since you became pregnant, about how often have you used any insect repellent spray, lotion, or towelettes on
yourself or someone else?
Every day, ................................................................................................ 01
A few times a week, ................................................................................. 02
About once a week, .................................................................................. 03
1-3 times a month, ................................................................................... 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR008. Did the insect repellent contain DEET? (DEET is usually listed next to the name of the product or in the ingredient
list on the label.)
YES .......................................................................................................... 1
NO ............................................................................................................ 2
USED BOTH REPELLENT WITH DEET AND WITHOUT DEET ............. 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR009. Since you became pregnant, have you been treated or did you treat other people in your home for lice or
scabies?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PR011)
REFUSED .......................................................................................... 9--97 (PR011)
DON’T KNOW .................................................................................... 9--98 (PR011)
Appendix A
A.1.3.a–51
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
PR010. What product did you use to treat lice or scabies?
PROBE: Anything else?
SELECT ALL THAT APPLY.
ACTICIN ................................................................................................... 01
ELIMITE ................................................................................................... 02
EURAX ..................................................................................................... 03
GENERIC/DRUGSTORE BRAND LICE/SCABIES PRODUCT................ 04
KWELL/KWELLEDA................................................................................. 05
NIX ........................................................................................................... 06
OVIDE ...................................................................................................... 07
RID ........................................................................................................... 08
STROMECTOL ........................................................................................ 09
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR011. When they are pregnant, women sometimes eat or chew on unusual items. Since you became pregnant, have
you eaten or chewed on any of the following items:
YES
NO
RF
DK
a.
b.
c.
d.
e.
f.
g.
Cornstarch, baking soda, or baking powder right out of the box?.......
Laundry starch? ..................................................................................
Dirt or clay? ........................................................................................
Paint chips? ........................................................................................
Burnt matches or ashes?....................................................................
Baby powder?.....................................................................................
Other non-food items (SPECIFY): ___________________________
1
1
1
1
1
1
1
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
Appendix A
A.1.3.a–52
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Pets and Pesticide Use
PP001. Now I’d like to ask about any pets you may have in your home.
PP002. Are there any pets that spend any time inside your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PP008)
REFUSED .......................................................................................... 9--97 (PP008)
DON’T KNOW .................................................................................... 9--98 (PP008)
PP003. What kind of pets are these?
SELECT ALL THAT APPLY.
DOG ......................................................................................................... 1
CAT .......................................................................................................... 2
SMALL MAMMAL (RABBIT, GERBIL, HAMSTER, GUINEA PIG,
FERRET, MOUSE)................................................................................ 3
BIRD......................................................................................................... 4
FISH OR REPTILE (TURTLE, SNAKE, LIZARD)..................................... 5
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PP004. Are any products ever used on your pets to control fleas, ticks, or mites? This includes flea collars, flea and tick
powders, shampoos, or other flea, tick and mite control products. (This does not include pills given to your pet to
control for fleas or other insects.)
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PP008)
REFUSED .......................................................................................... 9--97 (PP008)
DON’T KNOW .................................................................................... 9--98 (PP008)
PP005. When were any of these last used on any of your pets?
Within the last month, ............................................................................... 1
1–3 months ago,....................................................................................... 2
4–6 months ago, or .................................................................................. 3
More than 6 months ago?......................................................................... 4 (PP008)
REFUSED .......................................................................................... 9--97 (PP008)
DON’T KNOW .................................................................................... 9--98 (PP008)
PP006. What are the names of the products used on your pets to control fleas, ticks, or mites? Please show me the
products or containers if you have them.
_____________________________________________________
ENTER PRODUCT NAME FROM LIST
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.a–53
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
PP007. Did you personally handle or apply any of these products to your pets?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PP008. I would now like to ask about products that may have ever been used in your home or yard to control for ants,
termites, cockroaches, bees, wasps, moths, or other insects during the past 6 months.
PP009. When were any pesticides last used inside or outside this residence to control for insects?
Within the last month, ............................................................................... 1
1–3 months ago,....................................................................................... 2
4–6 months ago,....................................................................................... 3
More than 6 months ago, or ..................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(EOS)
(EOS)
(EOS)
(EOS)
PP010. In preparation for this interview, we asked that you gather together any of the pesticide cans or containers you
may have used in the last 6 months. You may also have letters from building maintenance about pesticide
application, or receipts from the exterminator that list which products were used. Please show me, or tell me the
names of the products that have been used within the last 6 months, either indoors or outdoors, to treat for
insects?
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT, LETTER, OR RECEIPT IS PROVIDED.
_____________________________________________________
PRODUCT NAME FROM LIST
_____________________________________________________
REGISTRATION NUMBER IF KNOWN
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (EOS)
9--98 (EOS)
BEGIN LOOP PP01
LOOP:
CYCLE THROUGH PP011–PP016 FOR ALL INSECTICIDE PRODUCTS LISTED
IN PP010.
Appendix A
A.1.3.a–54
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
PP011. How was the {PRODUCT} applied?
SELECT ALL THAT APPLY.
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT IS PROVIDED.
SPRAY ..................................................................................................... 01
BOMB....................................................................................................... 02
POWDER ................................................................................................. 03
STRIP....................................................................................................... 04
MOTH BALLS........................................................................................... 05
FOAM ....................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PP012. Which of the following areas of your home were treated with {PRODUCT}? Was it…
YES
NO
RF
DK
1
1
1
1
1
1
1
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
1
2
9--97
9--98
a. The common living area, that is the room other than bedroom or
kitchen where you spend most of your time?......................................
b. The kitchen? .......................................................................................
c. Your bedroom? ...................................................................................
d. The basement?...................................................................................
e. Any other rooms? ...............................................................................
f. Outdoors, around the walls of your house or building?.......................
g. Outdoors, in the garden or yard? ........................................................
h. Common areas inside building but outside of your home or
apartment (public foyer or hallway, etc.)? ...........................................
PP013. Who applied the {PRODUCT}? Was it….
You, .......................................................................................................... 1
A professional exterminator, or................................................................. 2
Someone else? ........................................................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PP014. How often was the {PRODUCT} used in the past 6 months?
More than once a month, or ..................................................................... 1
Once a month or less? ............................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–55
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
BOX PP03
CHECK ITEM:
IF PP013 = “1,” CONTINUE WITH PP015.
OTHERWISE, GO TO END LOOP PP01.
PP015. When you applied the {PRODUCT}, did you usually wear any protective items such as gloves or a mask?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_PP01)
REFUSED .......................................................................................... 9--97 (EL_PP01)
DON’T KNOW .................................................................................... 9--98 (EL_PP01)
PP016. Which protective items did you wear?
SELECT ALL THAT APPLY.
GLOVES................................................................................................... 1
MASK ....................................................................................................... 2
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP PP01
LOOP:
CYCLE THROUGH PP011-PP016 FOR NEXT INSECTICIDE PRODUCT.
IF NO MORE PRODUCTS, GO TO NEXT SECTION.
Appendix A
A.1.3.a–56
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Occupational/Hobby Exposures
OH001. Now I would like to ask some questions about any schoolwork, jobs, volunteer work, and hobbies that you have
done recently. Please only include activities that you do or have done for at least 4 hours per week.
OH002. Are you currently a full- or part-time student? This includes vocational or technical schooling that may not be done
in a classroom.
PROBE: Do you go full-time or part-time?
NO, NOT A STUDENT ............................................................................. 1 (OH007)
YES, FULL-TIME STUDENT.................................................................... 2
YES, PART-TIME STUDENT ................................................................... 3
REFUSED .......................................................................................... 9--97 (OH007)
DON’T KNOW .................................................................................... 9--98 (OH007)
OH003. What type or types of school are you currently attending?
HIGH SCHOOL ........................................................................................ 1
TECHNICAL SCHOOL ............................................................................. 2
COLLEGE OR UNIVERSITY.................................................................... 3
GRADUATE SCHOOL ............................................................................. 4
PROFESSIONAL SCHOOL (E.G., MEDICAL, LAW, DENTAL) ............... 5
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH004. Please refer to this card and tell me, what best describes the place where you typically go to school?
PROBE: Is this indoors or outdoors?
SHOW CARD OH1.
SELECT ALL THAT APPLY.
CLASSROOM .......................................................................................... 01
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S HOME . 02
LABORATORY......................................................................................... 03
GARAGE OR SHOP ................................................................................ 04
MOTOR VEHICLE.................................................................................... 05
SOME OTHER LOCATION (SPECIFY): _________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–57
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
OH005. What is the address where you actually attend school most often?
HOME....................................................................................................... 1
VARIES (CONSTRUCTION, LANDSCAPING) ........................................ 2
HAVE EXACT ADDRESS ........................................................................ 3
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(OH007)
(OH007)
(OH007)
(OH007)
(OH007)
OH006. (Please tell me the address where you actually attend school most often.)
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH007. Now I would like to ask you about jobs you have had recently.
Since you became pregnant,
a. How many full-time jobs have you had? ......................................
b. How many part-time jobs have you had?.....................................
c. How many volunteer jobs have you had (fire department,
humane society, etc.)?.................................................................
NUMBER
RF
DK
|___|___|
|___|___|
9--97
9--97
9--98
9--98
|___|___|
9--97
9--98
BOX OH01
CHECK ITEM:
ADD THE NUMBER OF FULL-TIME, PART-TIME, AND VOLUNTEER JOBS
(NumberFullTimeJobs (OH007A), NumberPartTimeJobs (OH007B), AND
NumberVolunteerJobs (OH007C)) AND CREATE TotalNumberOfJobs. DO NOT
INCLUDE “9--97” OR “9--98” RESPONSES IN THE SUM.
IF OH007A-C ALL SOME COMBINATION OF “9--97” AND “9--98,”
TotalNumberOfJobs = “0”.
BOX OH02
CHECK ITEM:
IF TotalNumberOfJobs > 0, BEGIN LOOP OH01.
IF TotalNumberOfJobs = 0, GO TO OH020.
Appendix A
A.1.3.a–58
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
BEGIN LOOP OH01
LOOP:
CYCLE THROUGH BOX OH03–OH019 AS MANY TIMES AS THE NUMBER
CALCULATED IN TotalNumberOfJobs.
BOX OH03
CHECK ITEM:
IF TotalNumberOfJobs = 1, GO TO OH009.
OTHERWISE, CONTINUE WITH OH008.
OH008. {Now I’d like to ask some questions about each one of your paid or volunteer jobs, starting with the job where you
work the most hours/ Now think about the job where you work the next greatest number of hours}.
OH009. Are you currently employed at this job?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH010. For this job, what {is/was} your job title or occupation?
_____________________________________________________
JOB TITLE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH011. For this job, who {is/was} your employer?
_____________________________________________________
EMPLOYER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.a–59
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
OH012. What types of activities {do/did} you do most often at this job? For example, teach classes, work on the computer,
keep account books, file, photocopy, answer phone, wait tables, help customers, do lab work, or carpentry?
PROBE: Anything else?
_____________________________________________________
ACTIVITY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH013. In what kind of business or industry {is/was} this job? That is, what does this company make or do?
_____________________________________________________
INDUSTRY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH014. On average, how many hours a week {do/did} you usually work at this job?
|___|___|___|
NUMBER OF HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH015. {Does/Did} this include working a shift that {starts/started} after 2 pm?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH016. {Do/Did} you rotate among different shifts for this job?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–60
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
OH017. Please look at this card and tell me, what best describes the place where you typically {work/worked} for this job?
PROBE: Is this indoors or outdoors?
SHOW CARD OH2.
SELECT ALL THAT APPLY.
OFFICE AREA ......................................................................................... 01
STORE ..................................................................................................... 02
CLASSROOM .......................................................................................... 03
HOTEL OR MOTEL.................................................................................. 04
RESTAURANT ......................................................................................... 05
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S HOME . 06
HEALTHCARE FACILITY OR HOSPITAL................................................ 07
LABORATORY......................................................................................... 08
FACTORY, PLANT, OR PRODUCTION AREA........................................ 09
WAREHOUSE.......................................................................................... 10
GARAGE OR SHOP ................................................................................ 11
SALON ..................................................................................................... 12
LOADING DOCK...................................................................................... 13
CONSTRUCTION SITE............................................................................ 14
GROUNDS, YARD, OR GARDEN ........................................................... 15
MOTOR VEHICLE.................................................................................... 16
SOME OTHER LOCATION (SPECIFY): _________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH018. What is the address where you actually {work/worked} at this job?
HOME....................................................................................................... 1
VARIES (CONSTRUCTION, LANDSCAPING) ........................................ 2
HAVE EXACT ADDRESS ........................................................................ 3
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH019. Please tell me the address where you actually {work/worked} at this job.
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
(EL_OH01)
(EL_OH01)
(EL_OH01)
(EL_OH01)
(EL_OH01)
Appendix A
A.1.3.a–61
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
END LOOP OH01
LOOP:
IF NUMBER OF CYCLES < TotalNumberOfJobs, CYCLE THROUGH BOX
OH03–OH019 AGAIN.
AFTER NUMBER OF CYCLES = TotalNumberOfJobs, CONTINUE WITH OH020.
OH020. Now I want to ask about any cleaning products, chemicals, pesticides, radiation, or bacteria or viruses that you
may have worked around or used since you became pregnant at any job, school, or hobby. When answering
these questions, please consider all jobs, schools, and hobbies that you do for at least 4 hours per week. Do not
include regular household use.
BEGIN LOOP OH02
LOOP:
CYCLE THROUGH OH021–OH029 FOR CLEANING PRODUCTS, CHEMICALS,
PESTICIDES, DUSTS, FUMES, RADIATION, AND BACTERIA OR VIRUSES.
OH021. (In any {full or part-time job,} {volunteer job,} {school,} {or} hobby have you used or worked around):
any {cleaning products, such as bleach, ammonia, or detergents/chemicals, such as paints, fuels, solvents, oils,
glues, or hair or nail products/pesticides that you’ve mixed or applied/dusts, including wood or mining dust/fumes
or gases, such as from anesthetic gases, ethylene oxide, welding or asphalt fumes, or engine exhaust/radiation,
including x-rays, fluoroscopy, or radioisotopes/bacteria or viruses, such as those used in a laboratory setting}?
(Again, do not include regular household use.)
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_OH02)
REFUSED .......................................................................................... 9--97 (EL_OH02)
DON’T KNOW .................................................................................... 9--98 (EL_OH02)
OH022. Please tell me the name of (or describe) the {cleaning products/chemicals/pesticides/dusts/fumes or
gases/radiation/bacteria or viruses}?
_____________________________________________________
NAME OR DESCRIPTION OF EXPOSURE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH023. Do you handle or work directly with the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/
bacteria or viruses} or do you just work around it?
DON’T WORK DIRECTLY WITH THE MATERIAL .................................. 1
HANDLE DIRECTLY (POUR, TOUCH, ETC.) ......................................... 2
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–62
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
OH024. Now thinking of the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/bacteria or viruses}
that you just mentioned….
OH025. Since you became pregnant, how often did you wear or use personal protective equipment to protect yourself
from the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/bacteria or viruses}? By personal
protective equipment, I mean things like gloves, dust masks, goggles, aprons, lab coats, or other protective
clothing. Would you say you always, often, rarely, or never use personal protective equipment?
ALWAYS .................................................................................................. 1
OFTEN ..................................................................................................... 2
RARELY ................................................................................................... 3
NEVER ..................................................................................................... 4 (OH028)
REFUSED .......................................................................................... 9--97 (OH028)
DON’T KNOW .................................................................................... 9--98 (OH028)
OH026. Please look at this card and tell me which types of protective clothing or equipment have you worn?
PROBE: Any other protective clothing or equipment?
SHOW CARD OH3.
SELECT ALL THAT APPLY.
GLOVES................................................................................................... 01
OVERALLS .............................................................................................. 02
OVERCOAT (E.G., LAB COAT, SMOCK, APRON) ................................. 03
DUST MASK ............................................................................................ 04
RESPIRATOR .......................................................................................... 05
GOGGLES/SAFETY GLASSES/FACE SHIELD ...................................... 06
WORK BOOTS/SHOES ........................................................................... 09
LEAD APRON .......................................................................................... 08
SOMETHING ELSE (SPECIFY): _______________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH027. What type of respirator was it?
A half-mask chemical cartridge respirator, which is silicone or rubber
and covers your mouth and nose, ......................................................... 1
A full-mask chemical cartridge respirator, which is silicone or rubber
and covers your eyes, nose, and mouth, ............................................... 2
An air-supplied or SCBA respirator, or .................................................... 3
Some other kind of respirator? (SPECIFY): _______________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–63
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
OH028. Is there any kind of a ventilation system to remove exhaust, dust, smoke or fumes from the area? By ventilation
system we mean purposely opening windows or doors, using a fume hood, or other ventilation system.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_OH02)
REFUSED .......................................................................................... 9--97 (EL_OH02)
DON’T KNOW .................................................................................... 9--98 (EL_OH02)
OH029. What ventilation systems are present to remove exhaust, dust, smoke or fumes from the area? Is there….
SELECT ALL THAT APPLY.
General ventilation, meaning open doors or windows, fans, etc............... 01
A regular HVAC system for building and room heating and cooling, ........ 02
A fume hood, lab hood, or other partially enclosed equipment,................ 03
A glove box or other totally enclosed equipment, ..................................... 04
A portable exhaust hose or tube, such as those used for welding or to
attach to vehicle tailpipe, or ................................................................... 05
Some other type of ventilation system? (SPECIFY): ________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP OH02
LOOP:
IF NUMBER OF CYCLES < 7 CYCLE AGAIN.
IF NUMBER OF CYCLES = 7, END LOOP AND CONTINUE WITH NEXT
SECTION.
Appendix A
A.1.3.a–64
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Commuting
CO001. Next, I’ll be asking about commuting and how you travel from place to place.
CO002. Think of the longest regular commute that you take, to work, school, or elsewhere. By regular commute, I mean
someplace that you travel to at least 3 days a week. Since you became pregnant, how do you normally get to
your destination?
SELECT ALL THAT APPLY.
DOES NOT HAVE A REGULAR COMMUTE........................................... 0
CAR.......................................................................................................... 1
BUS .......................................................................................................... 2
TRAIN, SUBWAY, RAIL, OR LIGHT RAIL ............................................... 3
WALK, BIKE (NON-MOTORIZED) ........................................................... 4
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(CO004)
(CO004)
(CO004)
(CO004)
(CO004)
(CO004)
CO003. About how many minutes is this commute, one way? Be sure to include any routine side trips you make on the
way, such as stops at day care or school. Include only the time spent driving or sitting inside the car.
|___|___|___|
NUMBER OF MINUTES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CO004. Since you became pregnant, how do you normally get to other places, for example, shopping, doctor, visiting
friends, or church?
SELECT ALL THAT APPLY.
CAR.......................................................................................................... 1
BUS .......................................................................................................... 2
TRAIN, SUBWAY, RAIL, OR LIGHT RAIL ............................................... 3
WALK, BIKE (NON-MOTORIZED) ........................................................... 4
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–65
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
CO005. Next, I’d like to find out about how often you pump gasoline.
CO006. Since you became pregnant, about how often have you pumped or poured gasoline into a car, truck,
motorcycle, other motor vehicle, lawnmower, or other engine:
Every day, ................................................................................................ 01
4–6 times per week, ................................................................................. 02
2–3 times per week, ................................................................................. 03
Once a week, ........................................................................................... 04
One to three times a month, ..................................................................... 05
Less than once a month, or ...................................................................... 06
Never?...................................................................................................... 07
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–66
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Perceived Stress/Discrimination
SD001. The following questions ask about your feelings and thoughts during the last month. Please look at this card
and tell me how often you felt or thought a certain way.
SD002. In the last month, how often have you been upset because of something that happened unexpectedly?
SHOW CARD SD1.
Never,....................................................................................................... 1
Almost never, ........................................................................................... 2
Sometimes, .............................................................................................. 3
Fairly often, or .......................................................................................... 4
Very often? ............................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD003. In the last month, how often have you felt that you were unable to control the important things in your life?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD004. (In the last month,) how often have you felt nervous and “stressed”?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–67
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
SD005. (In the last month,) how often have you felt confident about your ability to handle your personal problems?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD006. (In the last month,) how often have you felt that things were going your way?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD007. (In the last month,) how often have you found that you could not cope with all the things that you had to do?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD008. (In the last month,) how often have you been able to control irritations in your life?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–68
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
SD009. (In the last month,) how often have you felt you were on top of things?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD010. (In the last month,) how often have you been angered because of things that were outside of your control?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD011. (In the last month,) how often have you felt difficulties were piling up so high that you could not overcome them?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD012. Now I’ll change the subject and ask about how you are treated, and whether you have experienced discrimination
in various situations.
By discrimination I mean being prevented from doing something, or being hassled or made to feel inferior
because of your gender, race, color or ethnicity, socioeconomic position or social class, religion, a disability, or
any other reason.
SD013. Have you experienced discrimination in school?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
NOT APPLICABLE ................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(SD015)
(SD015)
(SD015)
(SD015)
Appendix A
A.1.3.a–69
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
SD014. How often has this happened?
Almost never, ........................................................................................... 1
Sometimes, .............................................................................................. 2
Fairly often, or .......................................................................................... 3
Very often? ............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD015. Have you experienced discrimination when applying for a job?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
NOT APPLICABLE ................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(SD017)
(SD017)
(SD017)
(SD017)
SD016. How often has this happened?
Almost never, ........................................................................................... 1
Sometimes, .............................................................................................. 2
Fairly often, or .......................................................................................... 3
Very often? ............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD017. Have you experienced discrimination at work?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
NOT APPLICABLE ................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(SD019)
(SD019)
(SD019)
(SD019)
SD018. How often has this happened?
Almost never, ........................................................................................... 1
Sometimes, .............................................................................................. 2
Fairly often, or .......................................................................................... 3
Very often? ............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD019. Have you experienced discrimination getting housing?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
NOT APPLICABLE ................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(SD021)
(SD021)
(SD021)
(SD021)
Appendix A
A.1.3.a–70
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
SD020. How often has this happened?
Almost never, ........................................................................................... 1
Sometimes, .............................................................................................. 2
Fairly often, or .......................................................................................... 3
Very often? ............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD021. Have you experienced discrimination getting medical care?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
NOT APPLICABLE ................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(SD023)
(SD023)
(SD023)
(SD023)
SD022. How often has this happened?
Almost never, ........................................................................................... 1
Sometimes, .............................................................................................. 2
Fairly often, or .......................................................................................... 3
Very often? ............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD023. Have you experienced discrimination getting service in a store or restaurant?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
NOT APPLICABLE ................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(SD025)
(SD025)
(SD025)
(SD025)
SD024. How often has this happened?
Almost never, ........................................................................................... 1
Sometimes, .............................................................................................. 2
Fairly often, or .......................................................................................... 3
Very often? ............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD025. Have you experienced discrimination getting credit, bank loans, or a mortgage?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
NOT APPLICABLE ................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(SD027)
(SD027)
(SD027)
(SD027)
Appendix A
A.1.3.a–71
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
SD026. How often has this happened?
Almost never, ........................................................................................... 1
Sometimes, .............................................................................................. 2
Fairly often, or .......................................................................................... 3
Very often? ............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD027. Have you experienced discrimination on the street or in a public setting?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
NOT APPLICABLE ................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(SD029)
(SD029)
(SD029)
(SD029)
SD028. How often has this happened?
Almost never, ........................................................................................... 1
Sometimes, .............................................................................................. 2
Fairly often, or .......................................................................................... 3
Very often? ............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD029. Have you experienced discrimination from the police or in the courts?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
NOT APPLICABLE ................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(BOX SD01)
(BOX SD01)
(BOX SD01)
(BOX SD01)
SD030. How often has this happened?
Almost never, ........................................................................................... 1
Sometimes, .............................................................................................. 2
Fairly often, or .......................................................................................... 3
Very often? ............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX SD01
IF SD013, SD015, SD017, SD019, SD021, SD023, SD025, SD027, OR SD029 =
“1,” CONTINUE WITH SD031.
OTHERWISE, GO TO SD032.
Appendix A
A.1.3.a–72
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
SD031. Do you currently feel that you’re being discriminated against for any reason?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD032. If you feel that you have been treated unfairly, do you usually:
Accept it as a fact of life, or ...................................................................... 1
Try to do something about it? ................................................................... 2
N/A, HAS NOT BEEN TREATED UNFAIRLY .......................................... 3 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
SD033. And when you have been treated unfairly, do you usually:
Talk to other people about it, or................................................................ 1
Keep it to yourself?................................................................................... 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a –73
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Maternal Depression
MD001. Now, I will read a list of the ways you might have felt or behaved in the past 7 days. Please look at this card, and
tell me how often you have felt or thought a certain way.
SHOW CARD MD1.
MD002. You were bothered by things that usually don’t bother you.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD003. You did not feel like eating; your appetite was poor.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD004. You felt that you could not shake off the blues even with the help of your family or friends.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–74
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MD005. You felt you were just as good as other people.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD006. You had trouble keeping your mind on what you were doing.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD007. You felt depressed.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD008. You felt that everything you did was an effort.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–75
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MD009. You felt hopeful about the future.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD010. You thought your life had been a failure.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD011. You felt fearful.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD012. Your sleep was restless.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–76
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MD013. You were happy.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD014. You talked less than usual.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD015. You felt lonely.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD016. People were unfriendly.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–77
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MD017. You enjoyed life.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD018. You had crying spells.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD019. You felt sad.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD020. You felt that people dislike you.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–78
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
MD021. You could not get “going.”
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a –79
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Social Support
SS001. Next are some questions about the support that is available to you. For this section, please think about the time
since you became pregnant.
SS002. How many relatives do you have that you feel close to—people you feel comfortable with, can talk with about
personal things, or can ask for help if you need it? Include your husband, parents, children, and other relatives.
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
SS003. How many close friends do you have that you feel close to—people you feel comfortable with, can talk with
about personal things, or can ask for help if you need it?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
SS004. People sometimes look to others for companionship, assistance, or other types of support. Please refer to this
card and tell me how often you feel each of the following kinds of support has been available to you if you needed
it. Remember to think about how you have felt since you became pregnant.
SHOW CARD SS1.
SS005. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to help you if you were confined to bed.
SHOW CARD SS1.
Rarely or none of the time, ....................................................................... 1
A little of the time,..................................................................................... 2
Some of the time, ..................................................................................... 3
Most of the time, or................................................................................... 4
All of the time?.......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–80
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
SS006. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone you could count on to listen to you when you need to talk.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS007. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to give you good advice about a crisis.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS008. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to take you to the doctor if you needed it.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–81
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
SS009. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone who shows you love and affection.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS010. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to have a good time with.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS011. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to give you information to help you understand a situation.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–82
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
SS012. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to confide in or talk to about yourself or your problems.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS013. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone who hugs you.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS014. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to get together with for relaxation.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–83
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
SS015. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to prepare your meals if you were unable to do it yourself.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS016. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone whose advice you really want.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS017. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to do things with, to help you get your mind off things.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–84
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
SS018. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to help with daily chores if you were sick.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS019. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to share your most private worries and fears with.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS020. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to turn to for suggestions about how to deal with a personal problem.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–85
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
SS021. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to do something enjoyable with.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS022. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone who understands your problems.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS023. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to love and make you feel wanted.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–86
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Household Composition and Demographics: Part 2
DM001. These next questions are about your background and cultural heritage.
DM002. Were you born in the United States?
YES .......................................................................................................... 1 (DM005)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (DM005)
DON’T KNOW .................................................................................... 9--98 (DM005)
DM003. In what country were you born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DM004. About how long have you lived in the United States?
INTERVIEWER INSTRUCTION:
IF LESS THAN ONE YEAR, ENTER ”00”.
|___|___|
YEARS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DM005. Was your mother born in the United States?
YES .......................................................................................................... 1 (DM007)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (DM007)
DON’T KNOW .................................................................................... 9--98 (DM007)
DM006. In what country was your mother born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.a–87
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DM007. Was your father born in the United States?
YES .......................................................................................................... 1 (DM009)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (DM009)
DON’T KNOW .................................................................................... 9--98 (DM009)
DM008. In what country was your father born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DM009. These next questions are about the food eaten in your household in the last 12 months, and whether you were
able to afford the food you need.
DM010. Which of these statements best describes the food eaten in your household in the last 12 months:
Enough of the kinds of food we want to eat,............................................. 1
Enough, but not always the kinds of food we want,.................................. 2
Sometimes not enough food to eat, or ..................................................... 3
Often not enough food to eat?.................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(DM012)
(DM012)
(DM012)
(DM012)
DM011. Here are some reasons why people don’t always have enough to eat. For each one, please tell me if this is a
reason why you don’t always have enough to eat.
YES
NO
RF
DK
a.
b.
c.
d.
e.
f.
Not enough money for food? ..............................................................
Not enough time for shopping or cooking? .........................................
Too hard to get to the store? ..............................................................
On a diet? ...........................................................................................
No working stove available? ...............................................................
Not able to cook or eat because of health problems?.........................
1
1
1
1
1
1
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
DM012. Now I’m going to switch the subject and ask about health insurance.
DM013. Do you currently have insurance through a current or former employer or union either through yourself or another
family member?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–88
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DM014. (Do you currently have:)
Insurance purchased directly from an insurance company (by yourself or another family member)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM015. (Do you currently have:)
Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a
disability?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM016. (Do you currently have:)
TRICARE, VA, or other military health care?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM017. (Do you currently have:)
Indian Health Service?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM018. (Do you currently have:)
Medicare, for people 65 and older, or people with certain disabilities?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–89
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DM019. (Do you currently have:)
Any other type of health insurance or health coverage plan?
YES (SPECIFY): ___________________________________________ 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM020. Lastly, I’d like to find out how you see yourself in relation to other people in the United States.
DM021. Please look at this card. Think of this ladder as representing where people stand in the United States. At the
top of the ladder are the people who are the best off—those who have the most money, the most education and
the most respected jobs. At the bottom are the people who are the worst off—who have the least money, least
education, and the least respected jobs or no job.
Where would you place yourself on this ladder?
Please point to the rung where you think you stand at this time in your life, relative to other people in the United
States.
SHOW CARD DM1.
RUNG A ................................................................................................... 01
RUNG B ................................................................................................... 02
RUNG C ................................................................................................... 03
RUNG D ................................................................................................... 04
RUNG E ................................................................................................... 05
RUNG F.................................................................................................... 06
RUNG G ................................................................................................... 07
RUNG H ................................................................................................... 08
RUNG I..................................................................................................... 09
RUNG J .................................................................................................... 10
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.a–90
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Sensitive Questions—ACASI
AI001.
These next questions may be somewhat sensitive. Like all of the other questions that you have answered today,
your response will be kept confidential. If you are not sure about an answer, give us your best estimate. If you’d
like you can listen to the questions using headphones and enter your information directly into the computer. You
can also listen to the questions without headphones or I can read the questions to you.
Which would you prefer? Would you like to:
Listen to the questions on your own using headphones, ..........................
Listen to the questions on your own without headphones, or ...................
Have me read the questions to you?........................................................
AI002.
1
2
3 (EOS)
As part of an earlier interview, you may have completed some questions like this on your own. Would you like to
do the practice questions this time, or would you like to go right ahead to the interview?
DO PRACTICE QUESTIONS...................................................................
GO TO INTERVIEW .................................................................................
1
2
Appendix A
A.1.3.a–91
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Sensitive Questions—ACASI Practice
AP001. The first two 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.
AP002. What is your favorite soft drink?
Coke .........................................................................................................
Pepsi ........................................................................................................
Sprite ........................................................................................................
7-Up .........................................................................................................
Another soft drink .....................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
5
9--97
9--98
AP003. During a typical week, how many movies do you watch?
|___|___|
NUMBER OF MOVIES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
AP004. 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.
Please put on the headphones now. Your interviewer will help you adjust the volume. When you are ready, press
‘NEXT’ to see the first question.
Appendix A
A.1.3.a–92
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Sensitive Questions—ACASI Reproductive History (RH)
RH001. I’ll begin by asking about your current pregnancy.
RH002. Regarding this pregnancy, were you trying to become pregnant?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (RH004)
9--97 (RH004)
9--98 (RH004)
RH003. For about how many months were you trying to become pregnant? If 1 month or less, enter 1.
|___|___|
MONTHS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
RH004. Were you using birth control when you became pregnant?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (RH006)
9--97 (RH006)
9--98 (RH006)
RH005. When you became pregnant, what were you using? You may select more than one answer. Did you use birth
control pills, use a condom, use Depo-Provera or other shots or injections, use Natural family planning, including
rhythm or safe period by calendar, temperature, or cervical mucus, use a diaphragm, cervical cap or shield, use
foam, jelly, cream, a suppository or other insert, use a female condom or vaginal pouch, use the patch, Norplant,
the ring or Nuva ring, use a TODAY® sponge, use an IUD, coil or loop, use Plan B or the “Morning After” pill, use
withdrawal or “pulling out” or did you use some other method or do something else?
Birth control pills .......................................................................................
Condoms ..................................................................................................
Depo-Provera/shots/injections..................................................................
Natural family planning .............................................................................
Diaphragm/cap/shield...............................................................................
Foam/jelly/cream/insert ............................................................................
Female condom/vaginal pouch.................................................................
Patch/Norplant/Nuva ring .........................................................................
TODAY® sponge ......................................................................................
IUD/Coil/Loop ...........................................................................................
Plan B/”Morning After” pill.........................................................................
Withdrawal/pulling out ..............................................................................
Some other method ..................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
5
6
7
8
9
10
11
12
96
9--97
9--98
Appendix A
A.1.3.a–93
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
RH006. When you became pregnant, did you yourself actually want to have a baby at some time?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (RH008)
9--97 (RH008)
9--98 (RH008)
RH007. So would you say you became pregnant too soon, at about the right time, or later than you wanted?
Too soon ..................................................................................................
Right time .................................................................................................
Later .........................................................................................................
Didn’t care ................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
9--97
9--98
RH008. How tall are you without shoes?
|___|
NUMBER OF FEET
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
RH08A. How tall are you without shoes?
RESPONDENT INSTRUCTION:
Using the keypad, enter the number of inches.
|___|___|
NUMBER INCHES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
RH009. What was your weight just before you became pregnant?
First, select whether you would like to enter in pounds or kilograms. Press “NEXT” when you are done.
POUNDS ..................................................................................................
KILOGRAMS ............................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (RH09B)
9--97 (RH010)
9--98 (RH010)
Appendix A
A.1.3.a–94
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
RH09A. What was your weight just before you became pregnant?
Using the keypad, enter the number of pounds. Press “NEXT” when you are done.
|___|___|___|
WEIGHT IN POUNDS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
RH09B. What was your weight just before you became pregnant?
Using the keypad, enter the number of kilograms. Press “NEXT” when you are done.
|___|___|___|.|___|
WEIGHT IN KILOGRAMS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
RH010. Some women use a cleansing method known as douching. By douching, we mean putting a substance into your
vagina for medicinal or hygienic purposes.
RH011. Since you became pregnant, how often on average have you douched?
Never........................................................................................................
Less than once a month ...........................................................................
1–3 times a month....................................................................................
Once a week ...........................................................................................
2–4 times a week, ....................................................................................
5 or more times a week ............................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06
9--97
9--98
RH012. These next questions are about your reproductive history. I’ll begin by asking about your periods or menstrual
cycle.
RH013. How old were you when you had your first menstrual period?
|___|___|
AGE
(RH015)
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (RH015)
9--98
Appendix A
A.1.3.a–95
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
RH014. What grade were you in when you had your first menstrual period?
|___|___|
GRADE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
RH015. These next questions are about any previous pregnancies you may have had.
RH016. Before this pregnancy, have you ever been pregnant? Please include live births, miscarriages, stillbirths, ectopic
pregnancies, abortions and pregnancy terminations.
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (EOS)
9--97 (EOS)
9--98 (EOS)
RH017. How old were you when you became pregnant for the first time?
|___|___|
AGE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
RH018. In what month and year did your most recent pregnancy end?
Using the keypad, enter the month your most recent pregnancy ended. Press “NEXT” to enter the year.
|___|___|
MONTH
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (RH019)
9--98
RH018A. Using the keypad, enter the year your most recent pregnancy ended. Press “NEXT” when you are done.
|___|___|___|___|
YEAR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.a–96
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
RH019. Not including your current pregnancy, how many times have you been pregnant?
|___|___|
NUMBER OF PREGNANCIES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
RH020. How many of your pregnancies resulted in a live birth?
I___I___I
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
RH021. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
Diabetes?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
RH022. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
High blood pressure?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
RH023. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
Protein in your urine?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
Appendix A
A.1.3.a–97
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
RH024. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
Preeclampsia or toxemia?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
RH025. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
Early or premature labor?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
RH026. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
Anemia?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
RH027. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
Rh disease or isoimmunization?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
Appendix A
A.1.3.a–98
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
RH028. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
Group b strep?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
RH029. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
Herpes?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
RH030. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
Bacterial vaginosis?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
RH031. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
Pelvic inflammatory disease (PID) or infection in your tubes?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
Appendix A
A.1.3.a–99
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
RH032. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
A sexually transmitted disease or infection, such as chlamydia, syphilis, or gonorrhea?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
RH033. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health
care provider that you had:
Any other serious condition?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
BOX RH01
CHECK ITEM:
IF RH020 >= 1, CONTINUE WITH RH034.
OTHERWISE, GO TO RH042.
RH034. How many of your biological children are still living?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (RH037)
9--98 (RH037)
RH035. Were any of these children born with a birth defect or inherited disease or condition?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (RH037)
9--97 (RH037)
9--98 (RH037)
Appendix A
A.1.3.a–100
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
RH036. What birth defects or conditions were they born with? You may select more than one answer.
Congenital heart defect ............................................................................
Cleft lip or palate ......................................................................................
Any neural tube defect .............................................................................
Any abdominal defect ...............................................................................
Hypospadias.............................................................................................
Any limb defect.........................................................................................
Down syndrome .......................................................................................
Cystic fibrosis ...........................................................................................
Pyloric stenosis ........................................................................................
Sickle cell disease ....................................................................................
Fetal alcohol syndrome ............................................................................
Other condition or defect ..........................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06
07
08
09
10
11
96
9--97
9--98
RH037. Have you ever had any children who were born alive but died later?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (RH042)
9--97 (RH042)
9--98 (RH042)
RH038. How many of your children have died?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
BEGIN LOOP RH01
CYCLE THROUGH RH039–RH041 = NUMBER IN RH038.
9--97
9--98
Appendix A
A.1.3.a–101
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
RH039. How old {were they/was the first child/was the next child} when they died? Please enter the number of days,
weeks, months, or years, then select the unit of time. If this child was less than 1 day old, enter “1” and select
“Days”.
|___|___|
AGE
DAYS........................................................................................................
WEEKS ....................................................................................................
MONTHS..................................................................................................
YEARS .....................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
9--97
9--98
RH040. What caused their death? You may select more than one answer.
Birth defect ...............................................................................................
Preterm birth.............................................................................................
Respiratory distress syndrome .................................................................
SIDS .........................................................................................................
Complications from labor and delivery .....................................................
Injury/Injuries ............................................................................................
Cancer......................................................................................................
Other ........................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01 (RH041)
02
03
04
05
06
07
96
9--97
9--98
RH041. What birth defects or conditions were they born with? You may select more than one answer.
Congenital heart defect ............................................................................
Any neural tube defect .............................................................................
Any abdominal defect ...............................................................................
Any limb defect.........................................................................................
Down syndrome .......................................................................................
Cystic fibrosis ...........................................................................................
Sickle cell disease ....................................................................................
Fetal alcohol syndrome ............................................................................
Other condition or defect ..........................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06
07
08
96
9--97
9--98
END LOOP RH01
IF NUMBER OF CYCLES < NUMBER REPORTED IN NumChildrenDied
(RH038), CYCLE AGAIN.
IF NUMBER OF CYCLES = NUMBER REPORTED IN NumChildrenDied
(RH038), END LOOP AND CONTINUE WITH RH042.
Appendix A
A.1.3.a–102
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
RH042. Have you ever had any miscarriages?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (RH044)
9--97 (RH044)
9--98 (RH044)
RH043. How many?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
RH044. Have you ever had a stillborn baby? A stillborn baby is born at 24 weeks or later.
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (RH046)
9--97 (RH046)
9--98 (RH046)
RH045. How many?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
RH046. How many weeks pregnant were you when {this/the first/the next} baby was stillborn?
|___|___|
NUMBER OF WEEKS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
RH047. Have you ever had any abortions or other pregnancy terminations, including ectopic or tubal pregnancies?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (RH049)
9--97 (RH049)
9--98 (RH049)
Appendix A
A.1.3.a–103
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
RH048. How many?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX RH06
CHECK ITEM:
IF RH020 = 0, GO TO RH051.
OTHERWISE, CONTINUE WITH RH049.
RH049. Were any of your live-born babies born more than 3 weeks early?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
RH050. Did any of your full-term babies, who were born at 37 weeks or later, weigh less than 5lb 8oz or 2500 grams at
birth?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
RH051. Have you ever had twins, triplets, or other multiple births?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (RH053)
9--97 (RH053)
9--98 (RH053)
RH052. Were fertility drugs or treatments used to help you conceive that time?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
Appendix A
A.1.3.a–104
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
RH053. Have you ever had a Cesarean section?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
Appendix A
A.1.3.a–105
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Sensitive Questions—ACASI Drugs, Alcohol, and Cigarette Use
DA001. The next questions are about your use of cigarettes and alcohol just before your current pregnancy.
DA002. In the 3 months before you knew you were pregnant, did you smoke any cigarettes or cigarillos?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (DA005)
9--97 (DA005)
9--98 (DA005)
DA003. Did you smoke cigarettes or cigarillos:
Every day .................................................................................................
5 or 6 days a week ...................................................................................
2–4 days a week ......................................................................................
Once a week ............................................................................................
1–3 days a month.....................................................................................
Less than once a month ...........................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06
9--97
9--98
DA004. On days that you smoked, how many cigarettes or cigarillos did you smoke per day? If you smoked 1 or less per
day, enter “1.”
|___|___|
NUMBER PER DAY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DA005. In the 3 months before you knew you were pregnant, did you smoke or use any other tobacco products such
as pipes, cigars, chewing tobacco, or snuff?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (DA008)
9--97 (DA008)
9--98 (DA008)
Appendix A
A.1.3.a–106
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DA006. What did you use? You may select more than one answer.
Cigars .......................................................................................................
Pipes ........................................................................................................
Chewing tobacco......................................................................................
Snuff .........................................................................................................
Other ........................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
6
9--97
9--98
DA007. Did you use the other tobacco products:
Every day .................................................................................................
5 or 6 days a week ...................................................................................
2–4 days a week ......................................................................................
Once a week ............................................................................................
1–3 days a month.....................................................................................
Less than once a month ...........................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06
9--97
9--98
DA008. In the 3 months before you knew you were pregnant, did you use any nicotine patches, gum, or other nicotine
products?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (DA011)
9--97 (DA011)
9--98 (DA011)
DA009. What did you use? You may select more than one answer.
Nicotine patches.......................................................................................
Nicotine gum ............................................................................................
Other nicotine product ..............................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
6
9--97
9--98
Appendix A
A.1.3.a–107
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DA010. Did you use these other nicotine products:
Every day .................................................................................................
5 or 6 times a week ..................................................................................
2–4 times a week .....................................................................................
Once a week ............................................................................................
1–3 times a month....................................................................................
Less than once a month ...........................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06
9--97
9--98
DA011. Currently, do you smoke cigarettes or cigarillos?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (DA014)
9--97 (DA014)
9--98 (DA014)
DA012. Do you smoke cigarettes or cigarillos:
Every day .................................................................................................
5 or 6 days a week ...................................................................................
2–4 days a week ......................................................................................
Once a week ............................................................................................
1–3 days a month.....................................................................................
Less than once a month ...........................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06
9--97
9--98
DA013. On days that you smoke, how many cigarettes or cigarillos do you smoke per day? If you smoke 1 or less per
day, enter “1.”
|___|___|
NUMBER PER DAY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DA014. Currently, do you smoke or use any other tobacco products such as pipes, cigars, chewing tobacco, or snuff?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (DA017)
9--97 (DA017)
9--98 (DA017)
Appendix A
A.1.3.a–108
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DA015. What do you use? You may select more than one answer.
Cigars .......................................................................................................
Pipes ........................................................................................................
Chewing tobacco......................................................................................
Snuff .........................................................................................................
Other ........................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
6
9--97
9--98
DA016. Do you use these other tobacco products:
Every day .................................................................................................
5 or 6 days a week ...................................................................................
2-4 days a week .......................................................................................
Once a week ............................................................................................
1-3 days a month......................................................................................
Less than once a month ...........................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06
9--97
9--98
DA017. Currently, do you use nicotine patches, gum, or other nicotine products?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (DA020)
9--97 (DA020)
9--98 (DA020)
DA018. What do you use? You may select more than one answer.
Nicotine patches.......................................................................................
Nicotine gum ............................................................................................
Other nicotine product ..............................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
6
9--97
9--98
DA019. Do you use these other nicotine products:
Every day .................................................................................................
5 or 6 days a week ...................................................................................
2–4 days a week ......................................................................................
Once a week ............................................................................................
1–3 days a month.....................................................................................
Less than once a month ...........................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06
9--97
9--98
Appendix A
A.1.3.a–109
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
BOX DA01
CHECK ITEM:
IF DA002 = “1” AND DA011 = “2,” CONTINUE WITH DA020.
OTHERWISE, GO TO BOX DA02.
DA020. When did you stop smoking cigarettes or cigarillos?
More than 2 weeks before you knew you were pregnant .........................
Less than 2 weeks before you knew you were pregnant ..........................
When you found out you were pregnant...................................................
After you found out you were pregnant ....................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
9--97
9--98
BOX DA02
CHECK ITEM:
IF DA005 = “1” AND DA014 = “2,” CONTINUE WITH DA021.
OTHERWISE, GO TO DA022.
DA021. When did you stop using other tobacco products?
More than 2 weeks before you knew you were pregnant .........................
Less than 2 weeks before you knew you were pregnant ..........................
When you found out you were pregnant...................................................
After you found out you were pregnant ....................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
9--97
9--98
DA022. On average, about how many hours per day do people smoke in the same room as you, or near enough that
you can see or smell the smoke? Please consider all the places you are during the day, including at home, at
work, or some other place. If you are not exposed to smoke, enter “0.”
|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.a–110
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DA023. In the 3 months before you knew you were pregnant, how often did you drink alcoholic beverages including
wine, beer, drinks containing hard liquor, wine coolers, hard lemonade, or hard cider?
5 or more times a week ............................................................................
2–4 times a week .....................................................................................
Once a week ............................................................................................
1–3 times a month....................................................................................
Less than once a month ...........................................................................
Never........................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06 (DA027)
9--97 (DA027)
9--98 (DA027)
DA024. In the 3 months before you knew you were pregnant, on days that you drank alcoholic beverages, how many
did you have per day? If you drank one or less enter “1.”
|___|___|
NUMBER OF DRINKS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DA025. In the 3 months before you knew you were pregnant, how often did you have 5 or more drinks within a couple
of hours:
Never........................................................................................................
About once a month .................................................................................
About once a week ...................................................................................
About once a day .....................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
9--97
9--98
DA026. In the 3 months before you knew you were pregnant, on days that you drank alcoholic beverages, what type
or types did you drink? You may select more than one answer.
Wine .........................................................................................................
Beer..........................................................................................................
Hard Liquor/Mixed Drinks .........................................................................
Wine Coolers............................................................................................
Hard Lemonade/Hard Cider .....................................................................
Other ........................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
5
6
9--97
9--98
Appendix A
A.1.3.a–111
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DA027. How often do you currently drink alcoholic beverages?
5 or more times a week ............................................................................
2–4 times a week .....................................................................................
Once a week ............................................................................................
1–3 times a month....................................................................................
Less than once a month ...........................................................................
Never........................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06 (BOX DA03)
9--97 (DA032)
9--98 (DA032)
DA028. Currently, on days that you drink alcoholic beverages, how many did you have per day? If you drink 1 or less,
enter “1.”
|___|___|
NUMBER OF DRINKS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DA029. Currently, how often do you have 5 or more drinks within a couple of hours:
Never........................................................................................................
About once a month .................................................................................
About once a week ...................................................................................
About once a day .....................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
9--97
9--98
DA030. Currently, on days that you drink alcoholic beverages, what type or types did you drink? You may select more
than one answer.
Wine .........................................................................................................
Beer..........................................................................................................
Hard Liquor/Mixed Drinks .........................................................................
Wine Coolers............................................................................................
Hard Lemonade/Hard Cider .....................................................................
Other ........................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
5
6
9--97
9--98
BOX DA03
IF DA023 = ANY “1,” “2,” “3,” “4,” OR “5” AND DA027 = “6” CONTINUE WITH
DA031.
OTHERWISE, GO TO DA032.
Appendix A
A.1.3.a–112
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DA031. When did you stop drinking alcoholic beverages?
More than 2 weeks before you knew you were pregnant .........................
Less than 2 weeks before you knew you were pregnant ..........................
When you found out you were pregnant...................................................
After you found out you were pregnant ....................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
9--97
9--98
DA032. The following questions ask about any prescription drugs you used without a doctor’s prescription, in larger
amounts than prescribed, or for a longer period than prescribed. This includes your use of any recreational or
"street" drugs. Please remember that your answers to these questions are strictly confidential.
DA033. In the 3 months before you knew you were pregnant, did you use any:
Sedatives, including either barbiturates or sleeping pills without a doctor’s prescription, in larger amounts than
prescribed, or for a longer period than prescribed? For example, Amytal, Seconal, or Halcion.
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
DA034. In the 3 months before you knew you were pregnant, did you use any:
Tranquilizers or “nerve pills” (without a doctor’s prescription, in larger amounts than prescribed, or for a longer
period than prescribed)? For example, Librium, Valium, Ativan, or Xanax.
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
DA035. In the 3 months before you knew you were pregnant, did you use any:
Amphetamines or other stimulants (without a doctor’s prescription, in larger amounts than prescribed, or for a
longer period than prescribed)? For example, methamphetamine, Ritalin, Dexedrine, Ecstasy, or speed.
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
Appendix A
A.1.3.a–113
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DA036. In the 3 months before you knew you were pregnant, did you use any:
Analgesics or other prescription painkillers (without a doctor’s prescription, in larger amounts than prescribed, or
for a longer period than prescribed)? This does not include normal use of aspirin or Tylenol without codeine but
does include use of Tylenol with codeine, Percocet, Lortab, codeine, OxyContin, oxycodone, morphine,
methadone, or other prescription pain killers.
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
DA037. In the 3 months before you knew you were pregnant, did you use any:
Inhalants that you sniff or breathe to get high or to feel good? For example, Amylnitrate, nitrous oxide or
“whippets”, glue, gasoline or spray paint.
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
DA038. In the 3 months before you knew you were pregnant, did you use any:
Marijuana or hashish?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
DA039. In the 3 months before you knew you were pregnant, did you use any:
Cocaine, crack, or free base?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
Appendix A
A.1.3.a–114
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
DA040. In the 3 months before you knew you were pregnant, did you use any:
LSD or other hallucinogens? For example PCP, angel dust, peyote, or mescaline.
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
DA041. In the 3 months before you knew you were pregnant, did you use:
Heroin?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
Appendix A
A.1.3.a–115
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Sensitive Questions—ACASI—Family Income
FI001.
Family income is important in analyzing the data we collect and is often used in scientific studies to compare
groups of people who are similar. Please remember that all the data you provide is confidential.
FI002.
In {LAST CALENDAR YEAR}, did you, or any other family members receive income from wages and salaries,
including self-employment, and business and farm income? Please note, a family is a group of two or more
people who live together and who are related by birth, marriage, or adoption.
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
FI003.
1
2
9--97
9--98
In {LAST CALENDAR YEAR}, did you, or any other family members receive:
Income from family or friends?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
FI004.
1
2
9--97
9--98
In {LAST CALENDAR YEAR}, did you, or any other family members receive:
Income from child support or alimony?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
FI005.
1
2
9--97
9--98
In {LAST CALENDAR YEAR}, did you, or any other family members receive:
Income from interest-bearing checking accounts, savings accounts, IRAs or certificates of deposit, money market
funds, treasury notes, bonds, or other investments that earned interest , dividends received from stocks or mutual
funds, or net rental income from property, royalties, estates or trusts?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
Appendix A
A.1.3.a–116
Version 1/20/08
FI006.
Visit Type: T1 Mom
Target: Mother
In {LAST CALENDAR YEAR}, did you, or any other family members receive:
Income from unemployment benefits?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
FI007.
1
2
9--97
9--98
In {LAST CALENDAR YEAR}, did you, or any other family members receive:
Income from aid such as Temporary Assistance for Needy Families (TANF), welfare, WIC, public assistance,
general assistance, food stamps, or Supplemental Security Income?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
FI008.
1
2
9--97
9--98
In {LAST CALENDAR YEAR}, did you, or any other family members receive:
Income from Social Security, Railroad Retirement, workers’ compensation, disability, veteran benefits, or
pensions?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
FI009.
1
2
9--97
9--98
In {LAST CALENDAR YEAR}, did you, or any other family members receive:
Income from any other source?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
FI010.
1
2
9--97
9--98
Now thinking about all the sources of income we just talked about, was your total family income in {LAST
CALENDAR YEAR} before taxes:
$20,000 or more, or..................................................................................
Less than $20,000?..................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
Appendix A
A.1.3.a–117
Version 1/20/08
FI011.
Visit Type: T1 Mom
Target: Mother
Of these income groups, which category best represents {your/the total combined family} income during {LAST
CALENDAR YEAR}? Remember, a family is a group of two or more people who live together and who are related
by birth, marriage, or adoption.
Less than $4,999......................................................................................
$5,000–$9,999 .........................................................................................
$10,000–$19,999 .....................................................................................
$20,000–$29,999 .....................................................................................
$30,000–$39,999 .....................................................................................
$40,000–$49,999 .....................................................................................
$50,000–$74,999 .....................................................................................
$75,000–$99,999 .....................................................................................
$100,000–$199,000 .................................................................................
$200,000 or more .....................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
FI012.
9--97
9--98
Are there any other family members, not living in this household, who are also supported by this income?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
FI013.
01
02
03
04
05
06
07
08
09
10
1
2 (EOS)
9--97 (EOS)
9--98 (EOS)
How many other family members, not living in this household, are supported by this income?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.a–118
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Visit: Sensitive Questions—ACASI Domestic Abuse
AB001. The following questions are about your physical safety.
AB002. Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by anyone?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (AB008)
9--97 (AB008)
9--98 (AB008)
AB003. Was this by? You may select more than one answer.
Your husband or partner...........................................................................
Your parent...............................................................................................
Other adult family member .......................................................................
Someone you know, but not a family member..........................................
A stranger.................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
5
9--97
9--98
AB004. How often did this happen?
1 time........................................................................................................
2–3 times..................................................................................................
3 or more times ........................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
9--97
9--98
AB005. Since you’ve been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by anyone?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (AB008)
9--97 (AB008)
9--98 (AB008)
AB006. Was this by? You may select more than one answer.
Your husband or partner...........................................................................
Your parent...............................................................................................
Other adult family member .......................................................................
Someone you know, but not a family member..........................................
A stranger.................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
5
9--97
9--98
Appendix A
A.1.3.a–119
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
AB007. How often has this happened?
1 time........................................................................................................
2–3 times..................................................................................................
3 or more times ........................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
9--97
9--98
AB008. Thank you for answering these questions. Please let your interviewer know that you are done.
Appendix A
A.1.3.a– 120
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
T1 Mom Interview: Tracing Information
TR001. Finally, I need to ask you a few questions so that staff from the National Children’s Study may contact you again.
TR002. Sometimes if people move or change their telephone number, we have difficulty reaching them. Could I have the
names and telephone numbers of 1 or 2 friends or relatives not currently living with you who should know where
you could be reached in case we have trouble contacting you?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TR011)
REFUSED .......................................................................................... 9--97 (TR011)
DON’T KNOW .................................................................................... 9--98 (TR011)
TR003. I’d like to collect some basic contact information on this person/these people. What is the first person’s name?
________________
FIRST NAME
________________
LAST NAME
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (TR011)
9--98 (TR011)
TR004. What is his/her relationship to you?
MOTHER/FATHER .................................................................................. 01
BROTHER/SISTER.................................................................................. 02
AUNT/UNCLE .......................................................................................... 03
GRANDPARENT...................................................................................... 04
NEIGHBOR .............................................................................................. 05
FRIEND .................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TR005. What is his/her address?
_____________________________________________________
STREET
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (TR007)
9--98
Appendix A
A.1.3.a–121
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
TR006. What is his/her telephone number?
I__I__I__I – I__I__I__I – I__I__I__I__I
PHONE NUMBER ....................................................................................
NONE .................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91
9--97
9--98
TR007. Now I’d like to collect information on a second contact. What is this person’s name?
______________
FIRST NAME
__________________
LAST NAME
NO SECOND CONTACT PROVIDED................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91 (TR011)
9--97 (TR011)
9--98 (TR011)
TR008. What is his/her relationship to you?
MOTHER/FATHER .................................................................................. 01
BROTHER/SISTER.................................................................................. 02
AUNT/UNCLE .......................................................................................... 03
GRANDPARENT...................................................................................... 04
NEIGHBOR .............................................................................................. 05
FRIEND .................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TR009. What is his/her address?
_____________________________________________________
STREET
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (TR011)
9--98
Appendix A
A.1.3.a–122
Version 1/20/08
Visit Type: T1 Mom
Target: Mother
TR010. What is his/her telephone number?
I__I__I__I – I__I__I__I – I__I__I__I__I
PHONE NUMBER ....................................................................................
NONE .................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91
9--97
9--98
TR011. Finally, could you please tell me your Social Security Number or Individual Taxpayer Identification Number? The
National Children’s Study may use your Social Security Number to conduct health-related research by linking your
survey data with vital statistics and other health records. We also may use it if we need to locate you or your
family in the future. Except for these purposes, the Study will not release your Social Security Number to anyone,
including any government agency. Providing this information is voluntary. Whether or not you give us this number
will have no effect on any benefits you might receive. The National Children’s Study is authorized by the
Children’s Health Act of 2000 and the Public Health Service Act. (The Public Health Service Act authority is found
under Section 448 (42USC 285g).
|___|___|___| |___|___| |___|___|___|___|
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TR012. Thank you for answering these questions. This completes the interview portion of the visit.
Appendix A
A.1.3.b–1
Version 1/20/08
Visit Type: T1 Dad
Target: Father
T1 Dad Visit: Interview Introduction
IN001.
Thank you for agreeing to participate in this study. We are about to begin the interview portion of today’s home
visit, which will take about 30 minutes to complete. Your answers are important to us. There are no right or wrong
answers, just those that help us to understand your situation. There are questions about where you work, your
health, and your feelings during this interview and you can always refuse to answer any question or group of
questions. If you need a break at any time please let me know so that I can give you the materials to collect the
samples that are needed today.
IN002.
Are you ready to begin?
YES ..........................................................................................................
NO ............................................................................................................
1
2 (END INTERVIEW)
Appendix A
A.1.3.b–2
Version 1/20/08
Visit Type: T1 Dad
Target: Father
T1 Dad Visit: Demographics Part 1
DE001. I’ll begin by asking some questions about you.
DE002. How old are you
|___|___|___|
AGE IN YEARS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DE003. Now I’d like to ask about your marital status. What is your current marital status? Are you:
Married, .................................................................................................... 01
Not married but living together with a partner of the opposite sex,........... 02
Not married but living together with a partner of the same sex,................ 03
Widowed,.................................................................................................. 04
Divorced, .................................................................................................. 05
Separated, or............................................................................................ 06
Never been married?................................................................................ 07
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DE004. Do you consider yourself to be Hispanic, or Latino?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DE005)
REFUSED .......................................................................................... 9--97 (DE005)
DON’T KNOW .................................................................................... 9--98 (DE005)
DE005. Please give me the number of the group that represents Hispanic origin or ancestry.
SHOW CARD DE2.
PUERTO RICAN ...................................................................................... 01
CUBAN/CUBAN AMERICAN ................................................................... 02
DOMINICAN (REPUBLIC)........................................................................ 03
MEXICAN ................................................................................................. 04
MEXICAN AMERICAN ............................................................................. 05
CENTRAL OR SOUTH AMERICAN ......................................................... 06
OTHER..................................................................................................... 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–3
Version 1/20/08
Visit Type: T1 Dad
Target: Father
DE006. What race do you consider yourself to be? PROBE: Anything else?
SELECT ALL THAT APPLY.
White, ....................................................................................................... 1
Black or African American, ....................................................................... 2
Asian, ....................................................................................................... 3
Native Hawaiian or Other Pacific Islander, ............................................... 4
American Indian or Alaska Native, or ....................................................... 5
Some other race? (SPECIFY): _________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DE007. Please look at the card and tell me what is the highest degree or level of school that you have completed?
SHOW CARD DE3.
NO SCHOOL............................................................................................ 01
ELEMENTARY
NURSERY SCHOOL TO 4TH GRADE ...................................................... 02
5TH–6TH GRADE ....................................................................................... 03
7TH–8TH GRADE ....................................................................................... 04
HIGH SCHOOL
9TH GRADE ..............................................................................................
10TH GRADE ............................................................................................
11TH GRADE ............................................................................................
12TH GRADE (NO DIPLOMA)...................................................................
HIGH SCHOOL DIPLOMA .......................................................................
GED OR EQUIVALENT............................................................................
COLLEGE
SOME COLLEGE CREDITS, BUT LESS THAN 1 YEAR.........................
1 OR MORE YEARS OF COLLEGE, BUT NO DEGREE.........................
ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR
VOCATIONAL PROGRAM.......................................................................
ASSOCIATE DEGREE: ACADEMIC PROGRAM ....................................
BACHELOR’S DEGREE (e.g., BA, BS)....................................................
05
06
07
08
09
10
11
12
13
14
15
GRADUATE
MASTER’S DEGREE (e.g., MA, MS, MSW, MEng, MBA) ....................... 16
PROFESSIONAL SCHOOL DEGREE (e.g., MD, DDS, DVM, JD)........... 17
DOCTORAL DEGREE (e.g., Ph.D., Ed.D.) .............................................. 18
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–4
Version 1/20/08
Visit Type: T1 Dad
Target: Father
T1 Dad Visit: Paternal Medical History
MC001. The next questions are about medical conditions or health problems you have or have had.
MC002. Have you ever been told by a doctor or other health care provider that you had asthma?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC003. (Have you ever been told by a doctor or other health care provider that you had:)
Eczema or atopic dermatitis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC004. (Have you ever been told by a doctor or other health care provider that you had:)
Seasonal allergies?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC005. (Have you ever been told by a doctor or other health care provider that you had:)
Any other allergies?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC007)
REFUSED .......................................................................................... 9--97 (MC007)
DON’T KNOW .................................................................................... 9--98 (MC007)
Appendix A
A.1.3.b–5
Version 1/20/08
Visit Type: T1 Dad
Target: Father
MC006. What type of allergy do you have?
SELECT ALL THAT APPLY.
PEANUTS ................................................................................................ 1
BEE STINGS............................................................................................ 2
SHELLFISH.............................................................................................. 3
CATS........................................................................................................ 4
DOGS....................................................................................................... 5
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC007. (Have you ever been told by a doctor or other health care provider that you had:)
Hypertension or high blood pressure?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC008. (Have you ever been told by a doctor or other health care provider that you had:)
Diabetes?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC013)
REFUSED .......................................................................................... 9--97 (MC013)
DON’T KNOW .................................................................................... 9--98 (MC013)
MC009. Have you taken any medicine or received other medical treatment for this in the past 12 months?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC010. Have you ever taken insulin?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC013)
REFUSED .......................................................................................... 9--97 (MC013)
DON’T KNOW .................................................................................... 9--98 (MC013)
Appendix A
A.1.3.b–6
Version 1/20/08
Visit Type: T1 Dad
Target: Father
MC011. Were you taking medication by mouth (for example, pills) for diabetes?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC012. Were you taking Insulin, either by injection or by pump?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC013. (Have you ever been told by a doctor or other health care provider that you had:)
High cholesterol?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC014. (Have you ever been told by a doctor or other health care provider that you had:)
Any type of cancer?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC016)
REFUSED .......................................................................................... 9--97 (MC016)
DON’T KNOW .................................................................................... 9--98 (MC016)
MC015. What type or types of cancer were you diagnosed with?
SELECT ALL THAT APPLY.
BRAIN ...................................................................................................... 1
BREAST ................................................................................................... 2
COLON..................................................................................................... 4
HODGKIN’S LYMPHOMA ........................................................................ 5
LEUKEMIA ............................................................................................... 6
LIVER ....................................................................................................... 7
LUNG ....................................................................................................... 8
NON-HODGKIN’S LYMPHOMA............................................................... 9
PROSTATE .............................................................................................. 11
SKIN ......................................................................................................... 12
TESTICULAR ........................................................................................... 13
THYROID ................................................................................................. 14
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–7
Version 1/20/08
Visit Type: T1 Dad
Target: Father
MC016. (Have you ever been told by a doctor or other health care provider that you had:)
Sickle cell anemia or sickle cell trait?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC018)
REFUSED .......................................................................................... 9--97 (MC018)
DON’T KNOW .................................................................................... 9--98 (MC018)
MC017. Which do you have?
SICKLE CELL ANEMIA ............................................................................ 1
SICKLE CELL TRAIT ............................................................................... 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC018. (Have you ever been told by a doctor or other health care provider that you had:)
An autoimmune disorder such as rheumatoid arthritis, lupus, or scleroderma?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC020)
REFUSED .......................................................................................... 9--97 (MC020)
DON’T KNOW .................................................................................... 9--98 (MC020)
MC019. What type of autoimmune disorder were you diagnosed with?
RHEUMATOID ARTHRITIS ..................................................................... 01
LUPUS ..................................................................................................... 02
SCLERODERMA...................................................................................... 03
MULTIPLE SCLEROSIS .......................................................................... 04
GRAVES’ DISEASE ................................................................................. 05
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC020. (Have you ever been told by a doctor or other health care provider that you had:)
Migraines?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–8
Version 1/20/08
Visit Type: T1 Dad
Target: Father
MC021. (Have you ever been told by a doctor or other health care provider that you had:)
Epilepsy or seizures?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC022. (Have you ever been told by a doctor or other health care provider that you had:)
Sleep apnea?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC023. (Have you ever been told by a doctor or other health care provider that you had:)
Blindness or any severe vision impairment?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC024. (Have you ever been told by a doctor or other health care provider that you had:)
Deafness or any severe hearing impairment?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC025. (Have you ever been told by a doctor or other health care provider that you had:)
Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–9
Version 1/20/08
Visit Type: T1 Dad
Target: Father
MC026. (Have you ever been told by a doctor or other health care provider that you had:)
Autism, Asperger syndrome, or any other autism spectrum disorder?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC027. (Have you ever been told by a doctor or other health care provider that you had:)
Bipolar disorder?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC028. (Have you ever been told by a doctor or other health care provider that you had:)
Depression, other than bipolar disorder?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC029. (Have you ever been told by a doctor or other health care provider that you had:)
An anxiety disorder, such as generalized anxiety disorder or obsessive compulsive disorder (OCD)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (MC031)
REFUSED .......................................................................................... 9--97 (MC031)
DON’T KNOW .................................................................................... 9--98 (MC031)
MC030. What type of anxiety disorder were you diagnosed with?
SELECT ALL THAT APPLY.
GENERALIZED ANXIETY DISORDER .................................................... 01
OBSESSIVE COMPULSIVE DISORDER................................................. 02
SOCIAL PHOBIA...................................................................................... 03
SPECIFIC PHOBIA .................................................................................. 04
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–10
Version 1/20/08
Visit Type: T1 Dad
Target: Father
MC031. (Have you ever been told by a doctor or other health care provider that you had:)
HIV or AIDS?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC032. (Have you ever been told by a doctor or other health care provider that you had:)
Hepatitis B?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MC033. (Have you ever been told by a doctor or other health care provider that you had:)
Any other chronic or long lasting conditions?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
MC034. What other chronic condition or conditions were you diagnosed with?
(SPECIFY):________________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–11
Version 1/20/08
Visit Type: T1 Dad
Target: Father
T1 Dad Visit: Occupational/Hobby Exposures
OH001. Now I would like to ask some questions about any schoolwork, jobs, volunteer work, and hobbies that you have
done recently. Please only include activities that you do (or have done) for at least 4 hours a week.
OH002. Are you currently a full- or part-time student? This includes vocational or technical schooling that may not be done
in a classroom.
PROBE: Do you go full-time or part-time?
NO, NOT A STUDENT ............................................................................. 1 (OH007)
YES, FULL-TIME STUDENT.................................................................... 2
YES, PART-TIME STUDENT ................................................................... 3
REFUSED .......................................................................................... 9--97 (OH007)
DON’T KNOW .................................................................................... 9--98 (OH007)
OH003. What type or types of school are you currently attending?
HIGH SCHOOL ........................................................................................ 1
TECHNICAL SCHOOL ............................................................................. 2
COLLEGE OR UNIVERSITY.................................................................... 3
GRADUATE SCHOOL ............................................................................. 4
PROFESSIONAL SCHOOL (E.G., MEDICAL, LAW, DENTAL) ............... 5
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH004. Please refer to this card and tell me, what describes the place where you typically go to school?
SHOW CARD OH1.
SELECT ALL THAT APPLY.
CLASSROOM .......................................................................................... 01
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S HOME . 02
LABORATORY......................................................................................... 03
GARAGE OR SHOP ................................................................................ 04
MOTOR VEHICLE.................................................................................... 05
SOME OTHER LOCATION (SPECIFY): _________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH005. Now I would like to ask you about the jobs you have had recently. {In the past 3 months}:
a. How many full-time jobs have you had? ......................................
b. How many part-time jobs have you had?.....................................
c. How many volunteer jobs have you had (fire department,
humane society, etc.)?.................................................................
NUMBER
RF
DK
|___|___|
|___|___|
9--97
9--97
9--98
9--98
|___|___|
9--97
9--98
Appendix A
A.1.3.b–12
Version 1/20/08
Visit Type: T1 Dad
Target: Father
BOX OH02
CHECK ITEM:
IF TotalNumberOfJobs > 0, BEGIN LOOP OH01.
IF TotalNumberOfJobs = 0, GO TO OH020.
BEGIN LOOP OH01
LOOP:
CYCLE THROUGH BOX OH03–OH019 AS MANY TIMES AS THE NUMBER
CALCULATED IN TotalNumberOfJobs.
BOX OH03
CHECK ITEM:
IF TotalNumberOfJobs = 1, GO TO OH009.
OTHERWISE, CONTINUE WITH OH008.
OH006. {Now I’d like to ask some questions about each one of your paid or volunteer jobs, starting with the job where you
work the most hours/Now think about the job where you work the next greatest number of hours}”.
OH007. Are you currently employed at this job?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OH008. For this job, what {is/was} your job title or occupation?
_____________________________________________________
JOB TITLE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH009. For this job, who {is/was} your employer?
_____________________________________________________
EMPLOYER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.b–13
Version 1/20/08
Visit Type: T1 Dad
Target: Father
OH010. What types of activities {do/did} you do most often at this job? For example, teach classes, work on the computer,
keep account books, file, photocopy, answer phone, wait tables, help customers, do lab work, or carpentry?
PROBE: Anything else?
_____________________________________________________
ACTIVITY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH011. In what kind of business or industry {is/was} this job? That is, what does this company make or do?
_____________________________________________________
INDUSTRY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH012. On average, how many hours a week {do/did} you usually work at this job?
|___|___|___|
NUMBER OF HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OH013. Please look at this card and tell me, what best describes the place where you typically {work/worked} for this job?
SHOW CARD OH2.
SELECT ALL THAT APPLY.
OFFICE AREA ......................................................................................... 01
STORE ..................................................................................................... 02
CLASSROOM .......................................................................................... 03
HOTEL OR MOTEL.................................................................................. 04
RESTAURANT ......................................................................................... 05
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S HOME . 06
HEALTHCARE FACILITY OR HOSPITAL................................................ 07
LABORATORY......................................................................................... 08
FACTORY, PLANT, OR PRODUCTION AREA........................................ 09
WAREHOUSE.......................................................................................... 10
GARAGE OR SHOP ................................................................................ 11
SALON ..................................................................................................... 12
LOADING DOCK...................................................................................... 13
CONSTRUCTION SITE............................................................................ 14
GROUNDS, YARD, OR GARDEN ........................................................... 15
MOTOR VEHICLE.................................................................................... 16
SOME OTHER LOCATION (SPECIFY): _________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–14
Version 1/20/08
Visit Type: T1 Dad
Target: Father
END LOOP OH01
LOOP:
IF NUMBER OF CYCLES < TotalNumberOfJobs, CYCLE THROUGH BOX
OH03–OH013 AGAIN.
EOS
Appendix A
A.1.3.b–15
Version 1/20/08
Visit Type: T1 Dad
Target: Father
T1 Dad Visit: Paternal Mental Health
PM001. Now I’ll switch subjects and ask about your thoughts and feelings. I’ll start by asking about your spouse or
partner’s current pregnancy. Then I’ll ask about your physical and emotional well-being and about areas of your
life that could affect your physical and emotional well-being. It is important for us to get accurate information. In
order to do this, you will need to think carefully before answering the following questions.
PM002. Did you feel that she became pregnant sooner than you wanted, later than you wanted, or at about the right time?
SOONER.................................................................................................. 1
LATER...................................................................................................... 2
AT ABOUT THE RIGHT TIME.................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM003. Have you ever in your life had an attack of fear or panic when all of a sudden you felt very frightened, anxious, or
uneasy?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PM005)
REFUSED .......................................................................................... 9--97 (PM005)
DON’T KNOW .................................................................................... 9--98 (PM005)
PM004. Have you ever in your life had an attack when all of a sudden you became very uncomfortable, you either became
short of breath, dizzy, nauseous, or your heart pounded, or you thought you might lose control, die, or go crazy?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM005. Have you ever in your life had attacks of anger when all of a sudden you lost control and broke and smashed
something worth more than a few dollars?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM006. Have you ever in your life had attacks of anger when all of a sudden you lost control and hit or hurt someone?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PM008)
REFUSED .......................................................................................... 9--97 (PM008)
DON’T KNOW .................................................................................... 9--98 (PM008)
Appendix A
A.1.3.b–16
Version 1/20/08
Visit Type: T1 Dad
Target: Father
PM007. Have you ever had attacks of anger when all of a sudden you lost control and threatened to hit or hurt someone?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM008. Have you ever in your life had a period lasting several days or longer when most of the day you felt sad, empty or
depressed?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM009. Have you had a period lasting several days or longer where you were very discouraged about how things were
going in your life?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM010. Have you ever had a period lasting several days or longer when you lost interest in most things you usually enjoy
like work, hobbies, and personal relationships?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM011. Some people have periods lasting 4 days or longer when they feel much more exited and full of energy than
usual. Their minds go too fast. They talk a lot. They are very restless or unable to sit still and they sometimes do
things that are unusual for them, such as driving too fast or spending too much money. Have you ever had a
period like this lasting several days or longer?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM012. Have you ever had a period lasting 4 days or longer when most of the time you were very irritable, grumpy, or in a
bad mood?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PM014)
REFUSED .......................................................................................... 9--97 (PM014)
DON’T KNOW .................................................................................... 9--98 (PM014)
Appendix A
A.1.3.b–17
Version 1/20/08
Visit Type: T1 Dad
Target: Father
PM013. Have you ever had a period lasting 4 days or longer when most of the time you were so irritable that you either
started arguments, shouted at people, or hit people?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM014. Did you ever have a time in your life when you were a “worrier”—that is, when you worried a lot more about things
than other people with the same problems as you?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PM017)
REFUSED .......................................................................................... 9--97 (PM017)
DON’T KNOW .................................................................................... 9--98 (PM017)
PM015. Did you ever have a time in your life when you were much more nervous or anxious than most other people with
the same problems as you?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PM017)
REFUSED .......................................................................................... 9--97 (PM017)
DON’T KNOW .................................................................................... 9--98 (PM017)
PM016. Did you ever have a period lasting one month or longer when you were anxious and worried most days?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM017. Was there ever a time in your life when you felt very afraid or really, really shy with people, like meeting new
people, going to parties, going on a date, or using a public bathroom?
YES .......................................................................................................... 1 (PM019)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM018. Was there ever a time in your life when you felt very afraid or uncomfortable when you had to do something in
front of a group of people, like giving a speech or speaking in class?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PM022)
REFUSED .......................................................................................... 9--97 (PM022)
DON’T KNOW .................................................................................... 9--98 (PM022)
Appendix A
A.1.3.b–18
Version 1/20/08
Visit Type: T1 Dad
Target: Father
PM019. Was there ever a time in your life when you became very upset or nervous {whenever you were in a social
situation/when you had to do something in front of a group}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM020. Did you ever stay away from {social situations/situations where you had to do something in front of a group}
whenever you could because of your fear?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM021. Do you think your fear was ever much stronger than it should have been?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM022. Was there ever a time in your life when you felt afraid of either being in crowds, going to public places, traveling
by yourself, or traveling away from home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PM026)
REFUSED .......................................................................................... 9--97 (PM026)
DON’T KNOW .................................................................................... 9--98 (PM026)
PM023. Was there ever a time in your life when you became very upset or nervous whenever you were in crowds, public
places, or traveling?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM024. Did you every stay away from these situations whenever you could because of your fear?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–19
Version 1/20/08
Visit Type: T1 Dad
Target: Father
PM025. Do you think your fear was ever much stronger than it should have been?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM026. The next question is about concentration problems that usually start before the age of seven. These problems
include not being able to keep your mind on what you were doing, losing interest very quickly in games or work,
trouble finishing what you started without being distracted, and not listening when people spoke to you. During
your first years at school—say between the ages of 5 and 7—was there ever a period lasting 6 months or longer
when you had a lot more trouble with problems of this sort than most children?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PM027. Some young kids are very restless and fidgety and so impatient that they often interrupt people and have trouble
waiting their turn. Did you ever have a time before the age of 7 lasting 6 months or longer in your childhood when
you were like that?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–20
Version 1/20/08
Visit Type: T1 Dad
Target: Father
T1 Dad Visit: Household Composition and Demographics: Part 2
DM001. These next questions are about your background and cultural heritage.
DM002. Were you born in the United States?
YES .......................................................................................................... 1 (DM005)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (DM005)
DON’T KNOW .................................................................................... 9--98 (DM005)
DM003. In what country were you born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DM004. About how long have you lived in the United States?
INTERVIEWER INSTRUCTION:
IF LESS THAN ONE YEAR, ENTER “00”.
|___|___|
YEARS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DM005. Was your mother born in the United States?
YES .......................................................................................................... 1 (DM007)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (DM007)
DON’T KNOW .................................................................................... 9--98 (DM007)
DM006. In what country was your mother born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.b–21
Version 1/20/08
Visit Type: T1 Dad
Target: Father
DM007. Was your father born in the United States?
YES .......................................................................................................... 1 (DM009)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (DM009)
DON’T KNOW .................................................................................... 9--98 (DM009)
DM008. In what country was your father born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DM009. These next questions are about the food eaten in your household in the last 12 months, and whether you were
able to afford the food you need.
DM010. Which of these statements best describes the food eaten in your household in the last 12 months:
Enough of the kinds of food we want to eat,............................................. 1
Enough, but not always the kinds of food we want,.................................. 2
Sometimes not enough food to eat, or ..................................................... 3
Often not enough food to eat?.................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(DM012)
(DM012)
(DM012)
(DM012)
DM011. Here are some reasons why people don’t always have enough to eat. For each one, please tell me if this is a
reason why you don’t always have enough to eat.
a.
b.
c.
d.
e.
f.
Not enough money for food? ..............................................................
Not enough time for shopping or cooking? .........................................
Too hard to get to the store? ..............................................................
On a diet? ...........................................................................................
No working stove available? ...............................................................
Not able to cook or eat because of health problems?.........................
YES
NO
RF
DK
1
1
1
1
1
1
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
Appendix A
A.1.3.b–22
Version 1/20/08
Visit Type: T1 Dad
Target: Father
DM012. Now I’m going to switch the subject and ask about health insurance.
DM013. Do you currently have insurance through a current or former employer or union (of yourself or another family
member)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM014. (Do you currently have):
Insurance purchased directly from an insurance company (by yourself or another family member)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM015. (Do you currently have:)
Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a
disability?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM016. (Do you currently have:)
TRICARE, VA, or other military health care?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM017. (Do you currently have:)
Indian Health Service?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–23
Version 1/20/08
Visit Type: T1 Dad
Target: Father
DM018. (Do you currently have:)
Medicare, for people 65 and older, or people with certain disabilities?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM019. (Do you currently have:)
Any other type of health insurance or health coverage plan?
YES (SPECIFY): ___________________________________________ 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DM020. Lastly, I’d like to find out how you see yourself in relation to other people in the United States.
DM021. Please look at this card. Think of this ladder as representing where people stand in the United States. At the
top of the ladder are the people who are the best off—those who have the most money, the most education and
the most respected jobs. At the bottom are the people who are the worst off—who have the least money, least
education, and the least respected jobs or no job.
Where would you place yourself on this ladder?
Please point to the rung where you think you stand at this time in your life, relative to other people in the United
States.
SHOW CARD DM1.
RUNG A ................................................................................................... 01
RUNG B ................................................................................................... 02
RUNG C ................................................................................................... 03
RUNG D ................................................................................................... 04
RUNG E ................................................................................................... 05
RUNG F.................................................................................................... 06
RUNG G ................................................................................................... 07
RUNG H ................................................................................................... 08
RUNG I..................................................................................................... 09
RUNG J .................................................................................................... 10
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–24
Version 1/20/08
Visit Type: T1 Dad
Target: Father
T1 Dad Interview: Tracing Information
BOX TR01
CHECK ITEM:
IF RESIDENT FATHER, GO TO TR011.
OTHERWISE, CONTINUE WITH TR001.
TR001. Finally, I need to ask you a few questions so that staff from the National Children’s Study may contact you again.
TR002. Sometimes if people move or change their telephone number, we have difficulty reaching them. Could I have the
names and telephone numbers of 1 or 2 friends or relatives not currently living with you who should know where
you could be reached in case we have trouble contacting you?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TR011)
REFUSED .......................................................................................... 9--97 (TR011)
DON’T KNOW .................................................................................... 9--98 (TR011)
TR003. I’d like to collect some basic contact information on this person/these people. What is the first person’s name?
________________
FIRST NAME
________________
LAST NAME
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (TR011)
9--98 (TR011)
TR004. What is his/her relationship to you?
MOTHER/FATHER .................................................................................. 01
BROTHER/SISTER.................................................................................. 02
AUNT/UNCLE .......................................................................................... 03
GRANDPARENT...................................................................................... 04
NEIGHBOR .............................................................................................. 05
FRIEND .................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–25
Version 1/20/08
Visit Type: T1 Dad
Target: Father
TR005. What is his/her address?
_____________________________________________________
STREET
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (TR007)
9--98
TR006. What is his/her telephone number?
I__I__I__I – I__I__I__I – I__I__I__I__I
PHONE NUMBER ....................................................................................
NONE .................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91
9--97
9--98
TR007. Now I’d like to collect information on a second contact. What is this person’s name?
______________
FIRST NAME
__________________
LAST NAME
NO SECOND CONTACT PROVIDED................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91 (TR011)
9--97 (TR011)
9--98 (TR011)
TR008. What is his/her relationship to you?
MOTHER/FATHER .................................................................................. 01
BROTHER/SISTER.................................................................................. 02
AUNT/UNCLE .......................................................................................... 03
GRANDPARENT...................................................................................... 04
NEIGHBOR .............................................................................................. 05
FRIEND .................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.b–26
Version 1/20/08
Visit Type: T1 Dad
Target: Father
TR009. What is his/her address?
_____________________________________________________
STREET
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (TR011)
9--98
TR010. What is his/her telephone number?
I__I__I__I – I__I__I__I – I__I__I__I__I
PHONE NUMBER ....................................................................................
NONE .................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91
9--97
9--98
TR011. Finally, could you please tell me your Social Security Number or Individual Taxpayer Identification Number? The
National Children’s Study may use your Social Security Number to conduct health-related research by linking your
survey data with vital statistics and other health records. We also may use it if we need to locate you or your
family in the future. Except for these purposes, the Study will not release your Social Security Number to anyone,
including any government agency. Providing this information is voluntary. Whether or not you give us this number
will have no effect on any benefits you might receive. The National Children’s Study is authorized by the
Children’s Health Act of 2000 and the Public Health Service Act. (The Public Health Service Act authority is found
under Section 448 (42USC 285g).
|___|___|___| |___|___| |___|___|___|___|
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TR012. Thank you for answering these questions. This completes the interview portion of the visit.
Appendix A
A.1.3.c–1
Version 1/20/08
Visit: 16/17 Week Phone
Target: Mother
Pregnancy Phone Follow-Up—T 16–17 Weeks
BOX FY00
CHECK ITEM:
IF R NO LONGER PREGNANT ACCORDING TO CHESHIRE, GO TO FY003.
IF AN EARLY ULTRASOUND OBTAINED AND R HAS NOT LOST PREGNANCY
ACCORDING TO CHESHIRE, GO TO BOX FY01.
OTHERWISE, CONTINUE WITH FY001.
FY001. I’m going to start by asking you about how your pregnancy is progressing. We have your due date recorded as
{DUE DATE}. Is this still accurate?
YES .......................................................................................................... 1
NO, DATE IS DIFFERENT ....................................................................... 2
NO, PREGNANCY LOST ......................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(BOX FY01)
(FY003)
(BOX FY01)
(BOX FY01)
FY002. What is that due date?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (BOX FY01)
9--98 (BOX FY01)
FY003. I’m so sorry for your loss. I realize it may be difficult for you to talk about it, but it’s important for us to know when
you lost your baby. Can you please tell me the date when it happened?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
FY004. DID RESPONDENT REQUEST ADDITIONAL INFORMATION ON PREGNANCY LOSS?
YES ..........................................................................................................
NO ............................................................................................................
1 (FY047)
2 (FY047)
Appendix A
A.1.3.c–2
Version 1/20/08
Visit: 16/17 Week Phone
Target: Mother
BOX FY01
CHECK ITEM:
IF NO PREGNANCY DIARY ENTRIES RECEIVED ACCORDING TO IMS AND
NO RECORD OF R REFUSING PREGNANCY DIARY IN IMS, CONTINUE WITH
FY005.
IF RECORD OF R REFUSING PREGNANCY DIARY IN IMS, GO TO BOX FY02.
IF ONLY SOME PREGNANCY DIARY ENTRIES RECEIVED ACCORDING TO
IMS, GO TO FY007.
OTHERWISE, GO TO BOX FY02.
FY005. {I’m going to begin by asking you about your Pregnancy Diary.} Are you using the Pregnancy Diary we previously
gave you? This is the diary where you record pregnancy symptoms, such as spotting and nausea, and your intake
of vitamins, painkillers and specific foods.
YES .......................................................................................................... 1 (FY007)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (FY007)
DON’T KNOW .................................................................................... 9--98 (FY007)
DISPLAY INSTRUCTIONS:
IF AN EARLY ULTRASOUND OBTAINED THEN DISPLAY “{I’m going to begin by asking you about
your Pregnancy Diary}”
FY006. Is that because…
You’ve misplaced the diary or .................................................................. 1
You’ve forgotten to use it?........................................................................ 2
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(BOX FY02)
(BOX FY02)
(BOX FY02)
(BOX FY02)
(BOX FY02)
FY007. {I’m going to begin by asking you about your Pregnancy Diary}. Thank you for the diary entries that you’ve sent
us. Having this information really improves the quality of the NCS research. We have not yet received your
pregnancy diary entries for the week(s) of {DATES}. Because the information is very important to the study,
please send these entries in as soon as possible.
DISPLAY INSTRUCTIONS:
IF AN EARLY ULTRASOUND OBTAINED AND ONLY SOME PREGNANCY DIARY ENTRIES RECEIVED,
THEN DISPLAY “{I’m going to begin by asking you about your Pregnancy Diary}”
BOX FY02
CHECK ITEM:
IF RECORD OF R REFUSING PREGNANCY MEDICAL CARE LOG IN IMS,
THEN GO TO BOX FY03.
OTHERWISE, CONTINUE WITH FY008.
FY008. Are you using the Pregnancy Medical Care Log? This is the booklet that you or your doctor uses to record
information about your doctors visits.
Appendix A
A.1.3.c–3
Version 1/20/08
Visit: 16/17 Week Phone
Target: Mother
YES .......................................................................................................... 1 (BOX FY03)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (BOX FY03)
DON’T KNOW .................................................................................... 9--98 (BOX FY03)
FY009. Is that because…
You haven’t had a medical visit since our last visit with you,.................... 1
You’ve misplaced the log, or .................................................................... 2
You’ve forgotten to bring it to your medical visits? ................................... 3
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX FY03
CHECK ITEM:
IF RESPONDENT LOST EITHER THE PREGNANCY DIARY (FY006 CODED “1”)
OR THE PREGNANCY MEDICAL CARE LOG (FY009 CODED “2”), CONTINUE
WITH FY010.
IF RESPONDENT REFUSED EITHER THE PREGNANCY DIARY OR THE
MEDICAL CARE PROVIDER LOG, GO TO FY012.
IF RESPONDENT NOT USING PREGNANCY DIARY FOR ANY REASON
OTHER THAN LOSS (FY006 IN “2”,”6”,”7,” ”8”) OR NOT USING MED LOG FOR
ANY REASON OTHER THAN LOSS OR NO MEDICAL VISITS (FY009 IN
“3”,”6”,”7,” ”8”), GO TO FY011.
OTHERWISE, GO TO FY012.
FY010. We’ll get another {Pregnancy Diary/{and} Pregnancy Medical Care Log} in the mail to you today.
FY011. This information is very important to the study. Please keep the {log/{and the} diary} in a safe place {and
remember to {fill out the diary at the same time every week/{and} bring the log with you to all of your medical
visits}}.
FY012. I am now going to ask about visits to a doctor or other health care provider. Please include routine prenatal visits,
visits for sonograms or ultrasounds, an amniocentesis, and other pregnancy-related tests and procedures, as well
as any other visits to a doctor or other health care provider at a clinic, doctor’s office or HMO, emergency room, or
hospital outpatient department. Please refer to {the Pregnancy Medical Care Log that you received as part of this
study or to} any {other} personal record or calendar that you keep that would help you to remember the dates of
these visits. {I’ll be asking you to put a checkmark in the box next to each visit once you’ve finished telling me
about it.} If you have this information available, please go and get it now.
Appendix A
A.1.3.c–4
Version 1/20/08
Visit: 16/17 Week Phone
Target: Mother
FY013. {Since you became pregnant/Since {MONTH}} have you seen a doctor or heath care provider for any reason?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (FY036)
REFUSED .......................................................................................... 9--97 (FY036)
DON’T KNOW .................................................................................... 9--98 (FY036)
BEGIN LOOP FY01
LOOP:
CYCLE THROUGH FY014–FY016 FOR EACH VISIT TO A DOCTOR OR OTHER
HEALTH CARE PROVIDER.
FY014. {Beginning with the most recent visit, please give me the date of the visit./Please give me the date of the next
most recent visit.}
INTERVIEWER INSTRUCTION:
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY AND A FOUR DIGIT YEAR.
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
FY015. What kind of place did you go to—a clinic or health center, doctor’s office or HMO, a hospital emergency
room, a hospital outpatient department, or some other place?
CLINIC OR HEALTH CENTER ................................................................ 1
DOCTOR’S OFFICE OR HMO................................................................. 2
HOSPITAL EMERGENCY ROOM ........................................................... 3
HOSPITAL OUTPATIENT DEPARTMENT .............................................. 4
SOME OTHER PLACE (SPECIFY):_____________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FY016. What was the main reason for the visit?
Prenatal care (including sonograms, amniocentesis, or other pregnancy
Related procedures), ................................................................................ 1
Physical, .................................................................................................. 2
Sick visit, or .............................................................................................. 3
Some other reason? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(FY023)
(FY023)
(FY023)
(FY023)
(FY023)
Appendix A
A.1.3.c–5
Version 1/20/08
Visit: 16/17 Week Phone
Target: Mother
FY017. At this visit, what was your weight?
WEIGHT MEASURED..............................................................................
WEIGHT NOT MEASURED .....................................................................
1
2 (FY019)
FY018. (At this visit, what was your weight?)
|___|___|___|.|___|
WEIGHT
POUNDS ..................................................................................................
KILOGRAMS ............................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
FY019. At this visit, what was your blood pressure?
BLOOD PRESSURE MEASURED...........................................................
BLOOD PRESSURE NOT MEASURED ..................................................
1
2 (FY022)
FY020. (At this visit, what was your blood pressure?)
INTERVIEWER INSTRUCTION:
BOTH SYSTOLIC AND DIASTOLIC MUST BE ENTERED. IF ONE OR BOTH ARE UNKNOWN, SELECT
DK.
|___|___|___|
SYSTOLIC BLOOD PRESSURE
|___|___|___|
DIASTOLIC BLOOD PRESSURE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX FY05
CHECK ITEM:
IF FY020 = “RF” OR “DK,” CONTINUE WITH FY021.
OTHERWISE, GO TO FY022.
FY021. Was it normal, high or low?
NORMAL .................................................................................................. 1
HIGH ........................................................................................................ 2
LOW ......................................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.c–6
Version 1/20/08
Visit: 16/17 Week Phone
Target: Mother
FY022. At this visit, were any of the following procedures performed?
a.
b.
c.
d.
Ultrasound or sonogram? ...................................................................
Amniocentesis? ..................................................................................
CVS (Chorionic Villi Sampling)? .........................................................
Any other pregnancy-related test or procedure? (SPECIFY): ______
YES
1
1
1
1
NO
2
2
2
2
RF
9--97
9--97
9--97
9--97
DK
9--98
9--98
9--98
9--98
FY023. Did a doctor or other health care provider give you a diagnosis or tell you that you had any illness or other medical
condition?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (FY025)
REFUSED .......................................................................................... 9--97 (FY025)
DON’T KNOW .................................................................................... 9--98 (FY025)
FY024. What was the diagnosis?
SELECT ALL THAT APPLY.
ANEMIA.................................................................................................... 01
BACTERIAL VAGINOSIS......................................................................... 02
EARLY OR PREMATURE LABOR........................................................... 03
GESTATIONAL DIABETES...................................................................... 04
GROUP B STREP .................................................................................... 05
HERPES................................................................................................... 06
HIGH BLOOD PRESSURE ...................................................................... 07
ISOIMMUNIZATION................................................................................. 08
PREECLAMPSIA ..................................................................................... 09
PELVIC INFLAMMATORY DISEASE (PID) ............................................. 10
PROTEIN IN YOUR URINE ..................................................................... 11
RH DISEASE............................................................................................ 12
TOXEMIA ................................................................................................. 13
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FY025. Did you receive any vaccinations at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (FY027)
REFUSED .......................................................................................... 9--97 (FY027)
DON’T KNOW .................................................................................... 9--98 (FY027)
Appendix A
A.1.3.c–7
Version 1/20/08
Visit: 16/17 Week Phone
Target: Mother
FY026. What did you receive?
SELECT ALL THAT APPLY.
FLU/INFLUENZA...................................................................................... 1
HEPATITIS B ........................................................................................... 2
TETANUS/DIPHTHERIA .......................................................................... 3
MENINGOCOCCAL ................................................................................. 4
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FY027. If you haven’t yet, please put a checkmark in the box next to the visit you just told me about in your Pregnancy
Medical Care Log. Have you had any other visits to a doctor or other health care provider {since you became
pregnant/since {MONTH}}? Please include routine prenatal visits, as well as visits to a doctor or other health care
provider either at a clinic, doctor’s office or HMO, emergency room, or outpatient department for any other reason.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_FY01)
REFUSED .......................................................................................... 9--97 (EL_FY01)
DON’T KNOW .................................................................................... 9--98 (EL_FY01)
END LOOP FY01
LOOP:
IF FY027 = “1,” CYCLE AGAIN.
OTHERWISE, END LOOP AND CONTINUE WITH FY028.
FY028. {Since you became pregnant/Since {MONTH}} have you spent 1 or more nights in the hospital?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (FY036)
REFUSED .......................................................................................... 9--97 (FY036)
DON’T KNOW .................................................................................... 9--98 (FY036)
END LOOP FY02
LOOP:
CYCLE THROUGH FY029–FY035 FOR EACH HOSPITALIZATION.
Appendix A
A.1.3.c–8
Version 1/20/08
Visit: 16/17 Week Phone
Target: Mother
FY029. What was the admission date of your {next} most recent hospitalization?
INTERVIEWER INSTRUCTION:
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR.
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
FY030. How many nights did you stay at the hospital during this hospitalization?
|___|___|___|
NUMBER OF NIGHTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
FY031. Did a doctor or other health care provider give you a diagnosis while you were hospitalized?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (FY033)
REFUSED .......................................................................................... 9--97 (FY033)
DON’T KNOW .................................................................................... 9--98 (FY033)
FY032. What was the diagnosis?
SELECT ALL THAT APPLY.
DEHYDRATION ....................................................................................... 01
PRETERM LABOR................................................................................... 02
HYPEREMISIS......................................................................................... 03
PREECLAMPISA ..................................................................................... 04
RUPTURE OF MEMBRANES .................................................................. 05
KIDNEY DISORDER ................................................................................ 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FY033. Did you receive any treatments while you were hospitalized? Please include any vaccinations you may have
received.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (FY035)
REFUSED .......................................................................................... 9--97 (FY035)
DON’T KNOW .................................................................................... 9--98 (FY035)
Appendix A
A.1.3.c–9
Version 1/20/08
Visit: 16/17 Week Phone
Target: Mother
FY034. What treatments did you receive?
_____________________________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
FY035. If you haven’t yet, put a checkmark in the box next to the visit that you just told me about in your Pregnancy
Medical Care Log. Have you had any other hospitalizations {since you became pregnant/since {MONTH}}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP FY02
LOOP:
IF FY035 = “1,” CYCLE AGAIN.
OTHERWISE, CONTINUE WITH FY036.
FY036. Now I’m going to change the subject and ask you about your relationship with your spouse or partner.
Most people have disagreements in their relationships. Please tell me the approximate extent of agreement or
disagreement between you and your spouse or partner for each item.
FY037. DOES RESPONDENT VOLUNTEER “I DON’T HAVE A SPOUSE/PARTNER”?
R DOES NOT SAY ANYTHING ABOUT HAVING A
SPOUSE/PARTNER ................................................................................
R VOLUNTERS SHE DOES NOT HAVE A SPOUSE/PARTNER............
1
2 (FY046)
FY038. Philosophy of life. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.c–10
Version 1/20/08
Visit: 16/17 Week Phone
Target: Mother
FY039. Aims, goals, and things believed important. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FY040. Amount of time spent together. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FY041. Please tell me how often you do the following with your spouse or partner.
FY042. How often do you have an interesting chat?
Never,....................................................................................................... 1
Less than once a month, .......................................................................... 2
Once or twice a month, ............................................................................ 3
Once or twice a week, .............................................................................. 4
Once a day, or.......................................................................................... 5
More often? .............................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FY043. How often do you calmly discuss something?
Never,....................................................................................................... 1
Less than once a month, .......................................................................... 2
Once or twice a month, ............................................................................ 3
Once or twice a week, .............................................................................. 4
Once a day, or.......................................................................................... 5
More often? .............................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.c–11
Version 1/20/08
Visit: 16/17 Week Phone
Target: Mother
FY044. How often do you work together on a project?
Never,....................................................................................................... 1
Less than once a month, .......................................................................... 2
Once or twice a month, ............................................................................ 3
Once or twice a week, .............................................................................. 4
Once a day, or.......................................................................................... 5
More often? .............................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FY045. Please indicate the degree of happiness in your relationship. Are you:
Very unhappy, ......................................................................................... 1
Somewhat unhappy,................................................................................. 2
Fairly happy, ............................................................................................ 3
Mostly happy, or ....................................................................................... 4
Very happy? ............................................................................................. 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FY046. These are all the questions I have at this time. {We’ll send another {Pregnancy Diary} {and} {Medical Care
Provider Log} in the mail right away.} {Please remember to use the Pregnancy Diary and to bring the Pregnancy
Medical Care Log with you to any doctor’s visits you may have.} Thank you for your time.
FY047. Again, I’d like to say how sorry I am for your loss. {We’ll send the information packet you requested as soon as
possible.} Please accept our best wishes for a quick recovery. {We’ll call you again within a few months to see
how you’re doing.} Thank you for your time.
DISPLAY INSTRUCTION:
IF FY004 = “1,” DISPLAY “ {We’ll send the information packet you requested as soon as possible.}”
Appendix A
A.1.3.d–1
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Interview Introduction
IN001.
Thank you for agreeing to participate in this study. We are about to begin the interview portion of today’s visit,
which will take about 45 minutes to complete. Your answers are important to us. There are no right or wrong
answers, just those that help us to understand your situation. There are questions about where you live, your
lifestyle routines, and your pregnancy during this interview and you can always refuse to answer any question or
group of questions. If you need a bathroom break at any time please let me know so that I can give you the
materials to collect the samples that are needed today.
Before we start, can you get the medicines and any pesticide products that you were asked to gather for this
appointment?
IN002.
AFTER RESPONDENT GATHERS MATERIALS, OR INDICATES THAT SHE DOESN’T HAVE ANY TO
GATHER, SAY:
Are you ready to begin?
YES ..........................................................................................................
NO ............................................................................................................
1
2 (END INTERVIEW)
Appendix A
A.1.3.d–2
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Current Pregnancy Information
CP001. First, I’d like to update some information about your current pregnancy.
CP002. We currently have your due date listed as {DUE DATE}. Has this changed?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP004)
REFUSED .......................................................................................... 9--97 (CP004)
DON’T KNOW .................................................................................... 9--98 (CP004)
CP003. What is your new due date?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (BOX CP01)
9--98 (BOX CP01)
CP004. DID RESPONDENT GIVE DATE?
RESPONDENT GAVE COMPLETE DATE ..............................................
INTERVIEWER ENTERED 15 FOR DAY.................................................
1
2
CP005. Are you still planning to deliver your baby at {NAME OF HOSPITAL REPORTED AT T1}?
YES .......................................................................................................... 1 (CP007)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (CP007)
DON’T KNOW .................................................................................... 9--98 (CP007)
CP006. What is the name and address of this place where you now plan to have your baby?
_____________________________________________________
NAME OF BIRTH HOSPITAL/BIRTHING CENTER
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.d–3
Version 1/20/08
Visit Type: T3
Target: Mother
CP007. Since {MONTH}, have you been told by a doctor or other health care provider that you have any of the following
conditions? (Please think only of conditions that you learned of during this pregnancy.)
YES
NO
RF
DK
a.
Diabetes?............................................................................................................
1
2
9--97
9--98
b.
High blood pressure?..........................................................................................
1
2
9--97
9--98
c.
Protein in your urine?..........................................................................................
1
2
9--97
9--98
d.
Preeclampsia or toxemia? ..................................................................................
1
2
9--97
9--98
e.
Early or premature labor? ...................................................................................
1
2
9--97
9--98
f.
Anemia? .............................................................................................................
1
2
9--97
9--98
g.
Rh disease or isoimmunization? .........................................................................
1
2
9--97
9--98
h.
Group B strep? ...................................................................................................
1
2
9--97
9--98
i.
Herpes? ..............................................................................................................
1
2
9--97
9--98
j.
Bacterial Vaginosis? ...........................................................................................
1
2
9--97
9--98
k.
Pelvic inflammatory disease (PID), or infection in your tubes? ...........................
1
2
9--97
9--98
l.
Other sexually transmitted disease or infection, such as chlamydia, syphilis, or
gonorrhea? .........................................................................................................
1
2
9--97
9--98
m.
Any other serious condition? ..............................................................................
(SPECIFY):_____________________________________________________
1
2
9--97
9--98
BOX CP02
CHECK ITEM:
IF DELIVERY LOCATION FROM T1 = “9--97” OR “9--98", CONTINUE WITH
CP008.
OTHERWISE, CONTINUE WITH CP010.
CP008. Where do you plan to deliver your baby:
In a hospital, ............................................................................................. 1
A birthing center, ...................................................................................... 2
At home, or............................................................................................... 3 (CP010)
Some other place? .................................................................................. 4
REFUSED .......................................................................................... 9--97 (CP010)
DON’T KNOW .................................................................................... 9--98 (CP010)
Appendix A
A.1.3.d–4
Version 1/20/08
Visit Type: T3
Target: Mother
CP009. What is the name and address of this place?
_____________________________________________________
NAME OF BIRTH HOSPITAL/BIRTHING CENTER
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CP010. Since {MONTH} on how many days have you had a fever over 101 degrees? (IF NEEDED: or 38.3 degrees
Celsius?)
|___|___|___|
NUMBER OF DAYS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CP011. Since {MONTH}, have you used a swimming pool?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP013)
REFUSED .......................................................................................... 9--97 (CP013)
DON’T KNOW .................................................................................... 9--98 (CP013)
CP012. How many times did you use a swimming pool?
1–5 times,................................................................................................. 01
6–10 times,............................................................................................... 02
11–20 times, or......................................................................................... 03
More than 20 times?................................................................................. 04
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CP013. Since {MONTH}, have you used:)
A hot tub or whirlpool?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP015)
REFUSED .......................................................................................... 9--97 (CP015)
DON’T KNOW .................................................................................... 9--98 (CP015)
Appendix A
A.1.3.d–5
Version 1/20/08
Visit Type: T3
Target: Mother
CP014. How many times did you use a hot tub or whirlpool?
1–5 times,................................................................................................. 01
6–10 times,............................................................................................... 02
11–20 times, or......................................................................................... 03
More than 20 times?................................................................................. 04
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CP015. Since {MONTH}, have you used):
A sauna?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CP017)
REFUSED .......................................................................................... 9--97 (CP017)
DON’T KNOW .................................................................................... 9--98 (CP017)
CP016. How many times did you use a sauna?
1–5 times,................................................................................................. 01
6–10 times,............................................................................................... 02
11–20 times, or......................................................................................... 03
More than 20 times?................................................................................. 04
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CP017. Since {MONTH}, have you used:)
An electric blanket?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
CP018. How many times did you use an electric blanket?
1–5 times,................................................................................................. 01
6–10 times,............................................................................................... 02
11–20 times, or......................................................................................... 03
More than 20 times?................................................................................. 04
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–6
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Plans for Child
PC001. Now I’d like to find out more about your plans for caring for your baby. I will start with your plans for feeding your
baby.
PC002. Which of the following statements best describes your current feelings about breastfeeding your new baby?
I know I will breastfeed ............................................................................. 1
I think I might breastfeed .......................................................................... 2
I know I will not breastfeed ....................................................................... 3
I don’t know right now............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PC003. Now I’d like to find out more about your plans for your baby’s sleeping arrangements.
PC004. When you come home from the hospital, do you plan to have the baby sleep in your bedroom or in a different
room at night?
IN RESPONDENT’S ROOM .................................................................... 1
IN A DIFFERENT ROOM ......................................................................... 2
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PC005. What do you plan to have the baby sleep in at night?
Bassinette, ............................................................................................... 1
Crib,.......................................................................................................... 2
Co-sleeper,............................................................................................... 3
In bed or other place with you, or ............................................................. 4
In something else? (SPECIFY): ________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PC006. In what position do you plan to lay the baby down to sleep at night? On their…
Side, ........................................................................................................ 1
Stomach, or .............................................................................................. 2
Back? ....................................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–7
Version 1/20/08
Visit Type: T3
Target: Mother
PC007. What do you plan to have the baby sleep in for naps?
Bassinette, ............................................................................................... 1
Crib,.......................................................................................................... 2
Co-sleeper,............................................................................................... 3
In bed or other place with you, or ............................................................. 4
In something else? (SPECIFY): ________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PC008. In what position do you plan to lay the baby down for naps? On their…
Side, ........................................................................................................ 1
Stomach, or .............................................................................................. 2
Back? ....................................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PC009. Next, I’ll ask about smoking inside your home.
PC010. Which of the following statements best describes what your rules will be about smoking inside your home will be
once your baby is born?
No one will be allowed to smoke anywhere inside my home, .................. 1
Smoking will be allowed in some rooms at some times, or....................... 2
Smoking will be permitted anywhere inside my home .............................. 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–8
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Use of Medicines, Supplements, and Alternative Medicines
MU001. Next, I’d like to update some information you provided during your last visit in {MONTH} about your use of
prescription and over-the-counter medications and supplements.
MU002. May I please see the containers for any prescription, and non-prescription medicines and supplements, that you
used or took since {MONTH}? I’ll ask about prescription medications first.
RESPONDENT HAS CONTAINERS........................................................
RESPONDENT DOES NOT HAVE CONTAINERS..................................
1
2
BOX MU01
CHECK ITEM:
IF NO RECORDS WHERE MU010, MU014, OR MU003 != “2” AT LAST IN
PERSON INTERVIEW, GO TO MU006.
BEGIN LOOP MU01
LOOP:
FOR EACH RECORD WHERE MU010 != “2” OR MU003 != “2” OR MU014 != “2”
AT LAST IN-PERSON INTERVIEW, CYCLE THROUGH MU003–MU006.
MU003. Are you still taking {MEDICATION}?
YES .......................................................................................................... 1 (MU006)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (EL_MU01)
DON’T KNOW .................................................................................... 9--98 (EL_MU01)
MU004. On what date did you stop taking {MEDICATION}?
INTERVIEWER INSTRUCTION:
ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR.
IF RESPONDENT KNOWS MONTH AND YEAR, BUT NOT DAY, ENTER 15 FOR DAY.
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.d–9
Version 1/20/08
Visit Type: T3
Target: Mother
MU005. DID RESPONDENT GIVE DATE?
RESPONDENT GAVE COMPLETE DATE ..............................................
INTERVIEWER ENTERED 15 FOR DAY.................................................
1
2
MU006. How often {do/did} you use or take {MEDICATION}?
|___|___|
ENTER NUMBER
ENTER UNIT
PER DAY..................................................................................................
PER WEEK ..............................................................................................
PER MONTH............................................................................................
PER YEAR ...............................................................................................
AS NEEDED.......................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
9--95
9--97
9--98
END LOOP MU01
LOOP:
IF MORE RECORDS WHERE MU010 != “2” OR MU003 != “2” OR MU014 != “2”
AT LAST IN-PERSON INTERVIEW, CYCLE AGAIN.
OTHERWISE, CONTINUE WITH MU007.
MU007. At any time between {MONTH} and today, have you started any new medication for which a prescription is
needed? Include only those products prescribed by a health professional such as a doctor or dentist. Please
include prescription vitamins or minerals and prescriptions that you have started since {MONTH}, but are no
longer taking.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX MU02)
REFUSED .......................................................................................... 9--97 (BOX MU02)
DON’T KNOW .................................................................................... 9--98 (BOX MU02)
Appendix A
A.1.3.d–10
Version 1/20/08
Visit Type: T3
Target: Mother
MU008. {Please show me any you have taken since {MONTH}/ Please tell me the names of the prescription medications
and supplements that you have taken since {MONTH}.}
PROBE: Have you taken any other prescription medications since {MONTH} that we missed? Please include
prescriptions you may not be currently taking, but have finished since {MONTH}.
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER.
ACTIVATE LOOKUP AND SELECT MEDICATIONS FROM LIST. CHECK TO MAKE SURE THAT BOTH THE
BRAND AND TYPE OR FORMULA MATCH. IF A MEDICATION IS NOT ON LIST, ENTER THE FULL NAME
(INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
CONFIRM ALL MEDICATIONS ENTERED BEFORE MOVING TO NEXT SCREEN.
PRODUCT ON PRESCRIPTION MEDICINE LIST .................................. 1
PRODUCT NOT ON LIST (SPECIFY): __________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BEGIN LOOP MU02
LOOP:
CYCLE THROUGH MU009–MU015 FOR EACH NEW PRESCRIPTION ON
ROSTER.
MU009. {First/Next}, let’s talk about {MEDICATION}.
MU010. PRODUCT LABEL SEEN?
YES ..........................................................................................................
NO ............................................................................................................
1
2
MU011. RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK:
How is the {MEDICATION} taken:
By mouth, ................................................................................................. 01
Inhaled either by mouth or nose, .............................................................. 02
Injected,.................................................................................................... 03
Applied to the skin, such as a patch or creams, or ................................... 04
Some other way? (SPECIFY): _________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–11
Version 1/20/08
Visit Type: T3
Target: Mother
MU012. When did you start taking {MEDICATION}:
Within the last month, ............................................................................... 1
1–3 months ago, or .................................................................................. 2
More than 3 months ago?......................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MU013. When did you start taking {MEDICATION}:
Before you became pregnant, .................................................................. 1
In your first month of pregnancy, or.......................................................... 2
After your first month of pregnancy? ........................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MU014. Are you still taking {MEDICATION}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MU015. How often {do/did} you use or take {MEDICATION}?
|___|___|
ENTER NUMBER
ENTER UNIT
PER DAY..................................................................................................
PER WEEK ..............................................................................................
PER MONTH............................................................................................
PER YEAR ...............................................................................................
AS NEEDED.......................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
9--95
9--97
9--98
END LOOP MU02
LOOP:
CYCLE THROUGH MU009–MU015 FOR THE NEXT PRESCRIPTION
MEDICATION IN ROSTER.
WHEN FINISHED WITH ALL MEDICATIONS LISTED IN ROSTER CONTINUE
WITH BOX MU02.
Appendix A
A.1.3.d–12
Version 1/20/08
Visit Type: T3
Target: Mother
BOX MU02
CHECK ITEM:
IF NO RECORDS WHERE MU018 != “2” OR MU016 != “2” OR MU026 FROM
LAST IN PERSON INTERVIEW, GO TO MU018.
BEGIN LOOP MU03
LOOP:
FOR EACH RECORD WHERE MU018, MU016, OR MU026 != “2” AT LAST INPERSON INTERVIEW, CYCLE THROUGH MU016–MU017.
MU016. Are you still taking {PRODUCT}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MU017. Since {MONTH} how often have you used or taken {PRODUCT}:
Less than once a month, .......................................................................... 01
Once a month,.......................................................................................... 02
2–3 times a month (but less than once a week), ...................................... 03
1–2 times a week, .................................................................................... 04
3–4 times a week, .................................................................................... 05
5–6 times a week, or ................................................................................ 06
Every day? ............................................................................................... 07
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP MU03
LOOP:
IF MORE RECORDS WHERE MU018, MU016, OR MU026 != “2” FROM LAST IN
PERSON INTERVIEW, CYCLE AGAIN.
OTHERWISE, CONTINUE WITH MU018.
MU018. At any time between {MONTH} and today, have you started taking any new over-the-counter or nonprescription
medications, or any nonprescription vitamins, minerals, herbals, or dietary supplements?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
Appendix A
A.1.3.d–13
Version 1/20/08
Visit Type: T3
Target: Mother
MU019. {Please show me any over-the-counter medications and non-prescription vitamins, minerals, herbals, or other
dietary supplements you have taken since {MONTH}./Please tell me the names of the over-the-counter
medications and non-prescription vitamins, minerals, herbals, or other dietary supplements that you have taken
since {MONTH}.}
PROBE: Have you taken any other over-the-counter medications or nonprescription vitamins, minerals, herbals,
or other dietary supplements since {MONTH} that we missed?
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER.
ACTIVATE LOOKUP AND SELECT MEDICATIONS FROM LIST. CHECK TO MAKE SURE THAT BOTH THE
BRAND AND TYPE OR FORMULA MATCH. IF A MEDICATION IS NOT ON LIST, ENTER THE FULL NAME
(INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
CONFIRM ALL MEDICATIONS ENTERED BEFORE MOVING TO NEXT SCREEN.
PRODUCT ON PRESCRIPTION MEDICINE LIST .................................. 1
PRODUCT NOT ON LIST (SPECIFY): __________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BEGIN LOOP MU04
LOOP:
CYCLE THROUGH MU020–MU026 FOR EACH OTC ON ROSTER.
MU020. {First/Next}, let’s talk about {PRODUCT}.
MU021. WAS PRODUCT LABEL SEEN?
YES ..........................................................................................................
NO ............................................................................................................
1
2
MU022. RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK:
How is this {PRODUCT} taken:
By mouth, ................................................................................................. 01
Inhaled either by mouth or nose, .............................................................. 02
Injected,.................................................................................................... 03
Applied to the skin, such as a patch or creams, or ................................... 04
Some other way? (SPECIFY): _________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–14
Version 1/20/08
Visit Type: T3
Target: Mother
MU023. When did you start taking {PRODUCT}:
Within the last month, ............................................................................... 1
1–3 months ago, or .................................................................................. 2
More than 3 months ago?......................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MU024. When did you start taking {PRODUCT}:
Before you became pregnant, .................................................................. 1
In your first month of pregnancy, or.......................................................... 2
After your first month of pregnancy? ........................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MU025. Since {MONTH}, how often have you taken {PRODUCT}:
Less than once a month, .......................................................................... 01
Once a month,.......................................................................................... 02
2–3 times a month (but less than once a week), ...................................... 03
1–2 times a week, .................................................................................... 04
3–4 times a week, .................................................................................... 05
5–6 times a week, or ................................................................................ 06
Every day? ............................................................................................... 07
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MU026. Are you still taking {PRODUCT}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP MU04
LOOP:
CYCLE THROUGH MU020–MU026 FOR THE NEXT OTC IN ROSTER.
WHEN FINISHED WITH ALL OTCS LISTED IN ROSTER, CONTINUE WITH
NEXT SECTION.
Appendix A
A.1.3.d–15
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Doctor Visits and Hospitalizations
DV001. I am now going to ask some questions about visits to a doctor or other health care provider. Please include
routine prenatal visits, visits for sonograms or ultrasounds, an amniocentesis, and other pregnancy-related tests
and procedures, as well as any other visits to a doctor or other health care provider at a clinic, doctor’s office or
HMO, emergency room, or hospital outpatient department. Please refer to {the Pregnancy Medical Care Log that
you received as part of this study or to} any {other} personal record or calendar that you keep that would help you
to remember the dates of these visits. If you have this information available, please go and get it now.
BOX DV00
CHECK ITEM:
IF CP005 = 1, GO TO BEGIN LOOP DV01.
OTHERWISE, CONTINUE WITH DV002.
DV002. Since {MONTH} have you seen a doctor or heath care provider for any reason?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
BEGIN LOOP DV01
LOOP:
CYCLE THROUGH DV003-DV016 FOR EACH VISIT TO A DOCTOR OR OTHER
HEALTH CARE PROVIDER.
DV003. {Beginning with the most recent visit, please give me the date of the visit./Please give me the date of the next
most recent visit.}
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DV004. What kind of place did you go to—a clinic or health center, doctor’s office or HMO, a hospital emergency room, a
hospital outpatient department, or some other place?
CLINIC OR HEALTH CENTER ................................................................ 1
DOCTOR’S OFFICE OR HMO................................................................. 2
HOSPITAL EMERGENCY ROOM ........................................................... 3
HOSPITAL OUTPATIENT DEPARTMENT .............................................. 4
SOME OTHER PLACE (SPECIFY):_____________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–16
Version 1/20/08
Visit Type: T3
Target: Mother
DV005. What was the main reason for the visit?
Prenatal care (including sonograms, amniocentesis, or other
pregnancy-related procedures),............................................................. 1
Physical, .................................................................................................. 2
Sick visit, or ............................................................................................. 3
Some other reason? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(DV012)
(DV012)
(DV012)
(DV012)
(DV012)
DV006. At this visit, what was your weight?
WEIGHT MEASURED..............................................................................
WEIGHT NOT MEASURED .....................................................................
1
2 (DV008)
DV007. (At this visit, what was your weight?)
|___|___|___|.|___|
WEIGHT
POUNDS ..................................................................................................
KILOGRAMS ............................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
DV008. At this visit, what was your blood pressure?
BLOOD PRESSURE MEASURED...........................................................
BLOOD PRESSURE NOT MEASURED ..................................................
1
2 (DV011)
DV009. (At this visit, what was your blood pressure?)
|___|___|___|
SYSTOLIC BLOOD PRESSURE
|___|___|___|
DIASTOLIC BLOOD PRESSURE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
BOX DV02
CHECK ITEM:
IF DV009 = “9-97” OR “9-98”, CONTINUE WITH DV010.
OTHERWISE, GO TO DV011.
9--97
9--98
Appendix A
A.1.3.d–17
Version 1/20/08
Visit Type: T3
Target: Mother
DV010. Was it normal, high or low?
NORMAL .................................................................................................. 1
HIGH ........................................................................................................ 2
LOW ......................................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DV011. At this visit, were any of the following procedures performed?
a.
b.
c.
d.
YES
NO
RF
DK
1
1
1
1
2
2
2
2
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
Ultrasound or sonogram? ...................................................................
Amniocentesis? ..................................................................................
CVS (Chorionic Villus Sampling)? ......................................................
Other test or procedure? (SPECIFY):_________________________
DV012. Did a doctor or other health care provider give you a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DV014)
REFUSED .......................................................................................... 9--97 (DV014)
DON’T KNOW .................................................................................... 9--98 (DV014)
DV013. What was the diagnosis?
SELECT ALL THAT APPLY.
ANEMIA.................................................................................................... 1
BACTERIAL VAGINOSIS......................................................................... 2
EARLY OR PREMATURE LABOR........................................................... 3
GESTATIONAL DIABETES...................................................................... 4
GROUP B STREP .................................................................................... 5
HERPES................................................................................................... 6
HIGH BLOOD PRESSURE ...................................................................... 7
ISOIMMUNIZATION................................................................................. 8
PELVIC INFLAMMATORY DISEASE (PID) ............................................. 9
PREECLAMPSIA ..................................................................................... 10
PROTEIN IN YOUR URINE ..................................................................... 11
RH DISEASE............................................................................................ 12
TOXEMIA ................................................................................................. 13
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DV014. Did you receive any vaccinations at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DV016)
REFUSED .......................................................................................... 9--97 (DV016)
DON’T KNOW .................................................................................... 9--98 (DV016)
Appendix A
A.1.3.d–18
Version 1/20/08
Visit Type: T3
Target: Mother
DV015. What did you receive?
SELECT ALL THAT APPLY.
FLU/INFLUENZA...................................................................................... 1
HEPATITIS B ........................................................................................... 2
TETANUS/DIPHTHERIA .......................................................................... 3
MENINGOCOCCAL ................................................................................. 4
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DV016. Have you had any other visits to a doctor or other health care provider since {MONTH}? Please include routine
prenatal visits, as well as visits to a doctor or other health care provider either at a clinic, doctor’s office or HMO,
emergency room, or outpatient department for any other reason.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_DV01)
REFUSED .......................................................................................... 9--97 (EL_DV01)
DON’T KNOW .................................................................................... 9--98 (EL_DV01)
END LOOP DV01
LOOP:
IF DV016 = “1,” CYCLE AGAIN.
OTHERWISE, END LOOP AND CONTINUE WITH DV017.
DV017. Since {MONTH} have you spent at least one night in the hospital?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX DV04)
REFUSED .......................................................................................... 9--97 (BOX DV04)
DON’T KNOW .................................................................................... 9--98 (BOX DV04)
BEGIN LOOP DV02
LOOP:
CYCLE THROUGH DV018–DV024 FOR EACH HOSPITALIZATION.
DV018. What was the admission date of your {next} most recent hospitalization?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.d–19
Version 1/20/08
Visit Type: T3
Target: Mother
DV019. How many nights did you stay at the hospital during this hospitalization?
|___|___|___|
NUMBER OF NIGHTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DV020. Did a doctor or other health care provider give you a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DV022)
REFUSED .......................................................................................... 9--97 (DV022)
DON’T KNOW .................................................................................... 9--98 (DV022)
DV021. What was the diagnosis?
SELECT ALL THAT APPLY.
DEHYDRATION ....................................................................................... 01
PRETERM LABOR................................................................................... 02
HYPEREMISIS......................................................................................... 03
PREECLAMPSIA ..................................................................................... 04
RUPTURE OF MEMBRANES .................................................................. 05
KIDNEY DISORDER ................................................................................ 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DV022. Did you receive any treatments? Please include any vaccinations you may have received.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DV024)
REFUSED .......................................................................................... 9--97 (DV024)
DON’T KNOW .................................................................................... 9--98 (DV024)
DV023. What treatments did you receive?
_____________________________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DV024. Have you had any other hospitalizations since {MONTH}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–20
Version 1/20/08
Visit Type: T3
Target: Mother
END LOOP DV02
LOOP:
IF DV024 = “1,” CYCLE AGAIN.
OTHERWISE, CONTINUE WITH BOX DV04.
BOX DV04
CHECK ITEM:
IF ANY RECORD OF DV011A = “1,” THEN GO TO EOS.
IF VISIT TYPE = T3 PRIOR, GO TO EOS.
Appendix A
A.1.3.d–21
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Housing Characteristics
HC001. The next few questions ask about any recent additions or renovations to your home.
HC002. Since {MONTH}, have any additions been built onto your home to make it bigger?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HC003. Since {MONTH}, have any renovations or other construction been done in your home? Include only major
projects. Do not count projects that were just painting or wall papering.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
HC004. Which rooms were renovated?
PROBE: Any others?
SELECT ALL THAT APPLY.
KITCHEN.................................................................................................. 1
LIVING ROOM ......................................................................................... 2
HALL/LANDING ....................................................................................... 3
RESPONDENT’S BEDROOM.................................................................. 4
OTHER BEDROOM ................................................................................. 5
BATHROOM/TOILET ............................................................................... 6
BASEMENT.............................................................................................. 7
OTHER (SPECIFY): _________________________________________ 8
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–22
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Product Use
PR001. These questions ask about some different types of products you may have used to take care of yourself, your
family, or your home. Please choose your answer from one of these categories.
SHOW CARD PR1.
PR002. Since {MONTH}, how often have you used the following types of products?
SHOW CARD PR1.
A
LESS
FEW ABOUT
1–3
THAN
TIMES ONCE TIMES
ONCE NOT
EVERY
A
A
A
A
AT
DAY WEEK WEEK MONTH MONTH ALL
a. Bleach?.................................................
b. Disinfectants other than bleach, such
as Lysol? ..............................................
c. Window or glass cleaner?.....................
d. Carpet cleaner? ....................................
e. Any type of air fresheners including
spray, stick, aerosol, or plug-in? ...........
f. Other aerosols or sprays of any kind,
including hair spray?.............................
g. Paint or varnish?...................................
h. Turpentine, mineral spirits, or paint
thinner?.................................................
i. Other types of paint stripper? ...............
RF
DK
01
02
03
04
05
06 9--97 9--98
01
01
01
02
02
02
03
03
03
04
04
04
05
05
05
06 9--97 9--98
06 9--97 9--98
06 9--97 9--98
01
02
03
04
05
06 9--97 9--98
01
01
02
02
03
03
04
04
05
05
06 9--97 9--98
06 9--97 9--98
01
01
02
02
03
03
04
04
05
05
06 9--97 9--98
06 9--97 9--98
PR003. Since {MONTH}, about how often have candles or incense been burned inside your home?
Every day, ................................................................................................ 01
A few times a week, ................................................................................. 02
About once a week, .................................................................................. 03
1–3 times a month, ................................................................................... 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR004. Since {MONTH}, were the personal products that you have used, such as lotions, gels, creams, shampoos, or
soaps, usually scented, unscented, or do you use both scented and unscented products?
SCENTED ................................................................................................ 1
UNSCENTED ........................................................................................... 2
USE BOTH SCENTED AND UNSCENTED PRODUCTS ........................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–23
Version 1/20/08
Visit Type: T3
Target: Mother
PR005. Since {MONTH}, about how often have you, or anyone in your household, used scented products for your home
such as scented laundry detergents, fabric softener, or dish soaps? Do not include air fresheners, candles, or
incense.
Every day, ................................................................................................ 01
A few times a week, ................................................................................. 02
About once a week, .................................................................................. 03
1–3 times a month, .................................................................................. 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR006. Since {MONTH}, have you used any insect repellent such as spray, lotion, or towelettes on yourself or someone
else?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PR009)
REFUSED .......................................................................................... 9--97 (PR009)
DON’T KNOW .................................................................................... 9--98 (PR009)
PR007. Since {MONTH}, about how often have you used any insect repellent spray, lotion, or towelettes on yourself or
someone else?
Every day, ................................................................................................ 01
A few times a week, ................................................................................. 02
About once a week, .................................................................................. 03
1–3 times a month, .................................................................................. 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR008. Did the insect repellent contain DEET? (DEET is usually listed next to the name of the product or in the ingredient
list on the label.)
YES .......................................................................................................... 1
NO ............................................................................................................ 2
USED BOTH REPELLENT WITH DEET AND WITHOUT DEET ............. 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR009. Since {MONTH}, have you been treated or did you treat other people in your home for lice or scabies?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PR011)
REFUSED .......................................................................................... 9--97 (PR011)
DON’T KNOW .................................................................................... 9--98 (PR011)
Appendix A
A.1.3.d–24
Version 1/20/08
Visit Type: T3
Target: Mother
PR010. What product did you use to treat lice or scabies?
PROBE: Anything else?
SELECT ALL THAT APPLY.
ACTICIN ................................................................................................... 1
ELIMITE ................................................................................................... 2
EURAX ..................................................................................................... 3
GENERIC/DRUGSTORE BRAND LICE/SCABIES PRODUCT................ 4
KWELL/KWELLEDA................................................................................. 5
NIX ........................................................................................................... 6
OVIDE ...................................................................................................... 7
RID ........................................................................................................... 8
STROMECTOL ........................................................................................ 9
OTHER (SPECIFY): _________________________________________ 96
REFUSED ................................................................................................ 97
DON’T KNOW .......................................................................................... 98
PR011. When they are pregnant, women sometimes eat or chew on unusual items. Since {MONTH} have you eaten or
chewed on any of the following items:
a.
b.
c.
d.
e.
f.
g.
Cornstarch, baking soda, or baking powder right out of the box?.......
Laundry starch? ..................................................................................
Dirt or clay? ........................................................................................
Paint chips? ........................................................................................
Burnt matches or ashes?....................................................................
Baby powder?.....................................................................................
Other non-food items (SPECIFY): ___________________________
YES
NO
RF
DK
1
1
1
1
1
1
1
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
Appendix A
A.1.3.d–25
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Pets and Pesticide Use
PP001. Now I’d like to ask about any pets you may have in your home.
PP002. Are there any pets that spend any time inside your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PP008)
REFUSED .......................................................................................... 9--97 (PP008)
DON’T KNOW .................................................................................... 9--98 (PP008)
DISPLAY INSTRUCTION:
DISPLAY MONTH OF LAST INTERVIEW.
PP003. What kind of pets are these?
SELECT ALL THAT APPLY.
DOG ......................................................................................................... 1
CAT .......................................................................................................... 2
SMALL MAMMAL (RABBIT, GERBIL, HAMSTER, GUINEA PIG,
FERRET, MOUSE)................................................................................ 3
BIRD......................................................................................................... 4
FISH OR REPTILE (TURTLE, SNAKE, LIZARD)..................................... 5
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PP004. Are any products ever used on your pets to control fleas, ticks, or mites? This includes flea collars, flea and tick
powders, shampoos, or other flea, tick and mite control products. (This does not include pills given to your pet to
control for fleas or other insects.)
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PP008)
REFUSED .......................................................................................... 9--97 (PP008)
DON’T KNOW .................................................................................... 9--98 (PP008)
PP005. When were any of these last used on any of your pets?
Within the last month, ............................................................................... 1
1–3 months ago,....................................................................................... 2
4–6 months ago, or .................................................................................. 3
More than 6 months ago?......................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(PP008)
(PP008)
(PP008)
(PP008)
Appendix A
A.1.3.d–26
Version 1/20/08
Visit Type: T3
Target: Mother
PP006. What are the names of the products used on your pets to control fleas, ticks, or mites? Please show me the
products or containers if you have them.
_______________________________
ENTER PRODUCT NAME FROM LIST
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
PP007. Did you personally handle or apply any of these products to your pets?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PP008. I would now like to ask about products that may have been used in your home or yard to control for ants, termites,
cockroaches, bees, wasps, moths, or other insects during the past 3 months.
PP009. When were any pesticides last used inside or outside this residence to control for insects?
Within the last month, ............................................................................... 1
1–3 months ago,....................................................................................... 2
4–6 months ago,....................................................................................... 3
More than 6 months ago, or ..................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(EOS)
(EOS)
(EOS)
(EOS)
(EOS)
PP010. In preparation for this interview, we asked that you gather together any of the pesticide cans or containers you
may have used in the last 3 months. You may also have letters from building maintenance about pesticide
application, or receipts from the exterminator that list which products were used. Please show me, or tell me the
names of the products that have been used within the last 3 months, either indoors or outdoors, to treat for
insects?
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT, LETTER, OR RECEIPT IS PROVIDED.
_____________________________________________________
PRODUCT NAME FROM LIST
_____________________________________________________
REGISTRATION NUMBER IF KNOWN
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (EOS)
9--98 (EOS)
Appendix A
A.1.3.d–27
Version 1/20/08
Visit Type: T3
Target: Mother
BEGIN LOOP PP01
LOOP:
CYCLE THROUGH PP011–PP016 FOR ALL INSECTICIDE PRODUCTS LISTED
IN PP010.
PP011. How was the {PRODUCT} applied?
SELECT ALL THAT APPLY.
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT IS PROVIDED.
SPRAY ..................................................................................................... 01
BOMB....................................................................................................... 02
POWDER ................................................................................................. 03
STRIP....................................................................................................... 04
MOTH BALLS........................................................................................... 05
FOAM ....................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PP012. Which of the following areas of your home were treated with {PRODUCT}? Was it…
YES
NO
RF
DK
1
1
1
1
1
1
1
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
1
2
9--97
9--98
a. The common living area, that is the room other than bedroom or
kitchen where you spend most of your time?......................................
b. The kitchen? .......................................................................................
c. Your bedroom? ...................................................................................
d. The basement?...................................................................................
e. Any other rooms? ...............................................................................
f. Outdoors, around the walls of your house or building?.......................
g. Outdoors, in the garden or yard? ........................................................
h. Common areas inside building but outside of your home or
apartment (public foyer or hallway, etc.)? ...........................................
PP013. Who applied the {PRODUCT}? Was it….
You, .......................................................................................................... 1
A professional exterminator, or................................................................. 2
Someone else? ........................................................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–28
Version 1/20/08
Visit Type: T3
Target: Mother
PP014. How often was the {PRODUCT} used in the past 3 months:
More than once a month, or ..................................................................... 1
Once a month or less? ............................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX PP03
CHECK ITEM:
IF PP013 = “1,” CONTINUE WITH PP015.
OTHERWISE, GO TO END LOOP PP01.
PP015. When you applied the {PRODUCT}, did you usually wear any protective items such as gloves or a mask?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_PP01)
REFUSED .......................................................................................... 9--97 (EL_PP01)
DON’T KNOW .................................................................................... 9--98 (EL_PP01)
PP016. Which protective items did you wear?
SELECT ALL THAT APPLY.
GLOVES................................................................................................... 1
MASK ....................................................................................................... 2
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP PP01
LOOP:
CYCLE THROUGH PP011–PP016 FOR NEXT INSECTICIDE PRODUCT.
IF NO MORE PRODUCTS, GO TO NEXT SECTION.
Appendix A
A.1.3.d–29
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Occupational/Hobby Exposures
OU001. Now I would like to update some information about schoolwork, jobs, volunteer work, and hobbies that you have
done recently.
Please only include activities that you do or have done for 4 hours a week or longer.
OU002. Are you currently a full- or part-time student? This includes vocational or technical schooling that may not be done
in a classroom.
PROBE: Do you go full-time or part-time?
NO, NOT A STUDENT ............................................................................. 1 (BOX OU01)
YES, FULL-TIME STUDENT.................................................................... 2
YES, PART-TIME STUDENT ................................................................... 3
REFUSED .......................................................................................... 9--97 (BOX OU01)
DON’T KNOW .................................................................................... 9--98 (BOX OU01)
OU003. What type or types of school are you currently attending?
SELECT ALL THAT APPLY.
HIGH SCHOOL ........................................................................................ 1
TECHNICAL SCHOOL ............................................................................. 2
COLLEGE OR UNIVERSITY.................................................................... 3
GRADUATE SCHOOL ............................................................................. 4
PROFESSIONAL SCHOOL (E.G., MEDICAL, LAW, DENTAL) ............... 5
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OU004. Please refer to this card and tell me, what describes the place where you typically go to school?
SHOW CARD OU1.
SELECT ALL THAT APPLY.
CLASSROOM .......................................................................................... 01
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S
HOME.................................................................................................... 02
LABORATORY......................................................................................... 03
GARAGE OR SHOP ................................................................................ 04
MOTOR VEHICLE.................................................................................... 05
SOME OTHER LOCATION (SPECIFY): _________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–30
Version 1/20/08
Visit Type: T3
Target: Mother
OU005. What is the address where you actually attend school most often?
HOME....................................................................................................... 1
VARIES (CONSTRUCTION, LANDSCAPING) ........................................ 2
HAVE EXACT ADDRESS ........................................................................ 3
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(BOX OU01)
(BOX OU01)
(BOX OU01)
(BOX OU01)
(BOX OU01)
OU006. (Please tell me the address where you actually attend school most often.)
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX OU01
CHECK ITEM:
IF StillAtJob, StillAtJobNew, OR StillWorkingAtSameJob = “1” AT LAST
INTERVIEW, BEGIN LOOP OU01.
OTHERWISE, GO TO OU016.
BEGIN LOOP OU01
LOOP:
CYCLE THROUGH OU007–OU015 FOR EACH PREVIOUS JOB.
OU007. Are you still working as a {JobTitle} for {EmployerName}?
YES .......................................................................................................... 1 (OU009)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (OU009)
DON’T KNOW .................................................................................... 9--98 (OU009)
Appendix A
A.1.3.d–31
Version 1/20/08
Visit Type: T3
Target: Mother
OU008. On what date did you stop working at this job?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX OU02
CHECK ITEM:
IF OU007= “2”, GO TO EL_OU01.
OU009. On average, how many hours a week do you usually work at this job?
|___|___|___|
NUMBER OF HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU010. Does this include working a shift that starts after 2 pm?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OU011. Do you rotate among different shifts for this job?
YES ........................................................................................................ 1
NO ........................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–32
Version 1/20/08
Visit Type: T3
Target: Mother
OU012. Please look at the card and tell me which locations you typically work at for this job?
SHOW CARD OU2.
SELECT ALL THAT APPLY.
OFFICE AREA ......................................................................................... 01
STORE ..................................................................................................... 02
CLASSROOM .......................................................................................... 03
HOTEL OR MOTEL.................................................................................. 04
RESTAURANT ......................................................................................... 05
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S
HOME.................................................................................................... 06
HEALTHCARE FACILITY OR HOSPITAL................................................ 07
LABORATORY......................................................................................... 08
FACTORY, PLANT, OR PRODUCTION AREA........................................ 09
WAREHOUSE.......................................................................................... 10
GARAGE OR SHOP ................................................................................ 11
SALON ..................................................................................................... 12
LOADING DOCK...................................................................................... 13
CONSTRUCTION SITE............................................................................ 14
GROUNDS, YARD, OR GARDEN ........................................................... 15
MOTOR VEHICLE.................................................................................... 16
SOME OTHER LOCATION (SPECIFY): _________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OU013. Since {MONTH} has there been any change in the address where you actually work at this job?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_OU01)
REFUSED .......................................................................................... 9--97 (EL_OU01)
DON’T KNOW .................................................................................... 9--98 (EL_OU01)
OU014. What is the address where you actually work at this job?
HOME....................................................................................................... 1
VARIES (CONSTRUCTION, LANDSCAPING) ........................................ 2
HAVE EXACT ADDRESS ........................................................................ 3
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(EL_OU01)
(EL_OU01)
(EL_OU01)
(EL_OU01)
(EL_OU01)
Appendix A
A.1.3.d–33
Version 1/20/08
Visit Type: T3
Target: Mother
OU015. Please tell me the address where you actually work at this job.
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
END LOOP OU01
LOOP:
IF MORE JOBS, CYCLE AGAIN.
OTHERWISE CONTINUE WITH OU016.
OU016. At anytime between {MONTH} and today, did you start a new job?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (OU032)
REFUSED .......................................................................................... 9--97 (OU032)
DON’T KNOW .................................................................................... 9--98 (OU032)
OU017. Please tell me how many different full-time, part-time, or volunteer jobs you started.
Please only include activities that you do or have done for at least 4 hours per week.
a. How many full-time jobs have you had? ......................................
b. How many part-time jobs have you had?.....................................
c. How many volunteer jobs have you had (fire department,
humane society, etc.)?.................................................................
NUMBER
RF
DK
|___|___|
|___|___|
9--97
9--97
9--98
9--98
|___|___|
9--97
9--98
BOX OU02
CHECK ITEM:
ADD THE NUMBER OF FULL-TIME, PART-TIME, AND VOLUNTEER JOBS
(OU017A, OU017B, AND OU017C) AND CREATE TotalNumberOfJobsNew. DO
NOT INCLUDE “9--97” OR “9--98” RESPONSES IN THE SUM.
IF OU017A-C ALL SOME COMBINATION OF “9--97” AND “9--98,”
TotalNumberOfJobsNew = “0”.
Appendix A
A.1.3.d–34
Version 1/20/08
Visit Type: T3
Target: Mother
BOX OU03
CHECK ITEM:
IF TotalNumberOfJobsNew > “0”, BEGIN LOOP OU02.
IF TotalNumberOfJobsNew = “0”, GO TO OU032.
BEGIN LOOP OU02
LOOP:
CYCLE THROUGH BOX OU04–OU031 AS MANY TIMES AS THE NUMBER
CALCULATED IN TotalNumberOfJobsNew.
BOX OU04
CHECK ITEM:
IF TotalNumberOfJobsNew = “1”, GO TO OU019.
OTHERWISE, CONTINUE WITH OU018.
OU018. {Now I’d like to ask some questions about each one of your new jobs, starting with the job where you work the
most hours/Now think about the new job where you work the next greatest number of hours}.
OU019. On what date did you start working at this job?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU020. Are you currently working at this job?
YES .......................................................................................................... 1 (OU022)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OU021. On what date did you stop working at this job?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.d–35
Version 1/20/08
Visit Type: T3
Target: Mother
OU022. For this job, what {is/was} your job title or occupation?
_________________________________________________________
JOB TITLE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU023. For this job, who {is/was} your employer?
_____________________________________________________
EMPLOYER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU024. What types of activities {do/did} you do most often at this job? For example, teach classes, work on the computer,
keep account books, file, photocopy, answer phone, wait tables, help customers, do lab work, or carpentry.
PROBE: Anything else?
_____________________________________________________
ACTIVITY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU025. In what kind of business or industry {is/was} this job? That is, what does this company make or do?
_____________________________________________________
INDUSTRY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU026. On average, how many hours a week {do/did} you usually work at this job?
|___|___|___|
NUMBER OF HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU027. {{Does/Did} this include working a shift that {starts/started} after 2 pm?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–36
Version 1/20/08
Visit Type: T3
Target: Mother
OU028. {Do/Did} you rotate among different shifts for this job?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OU029. Please look at this card and tell me, which locations you typically {work/worked} at for this job?
SHOW CARD OU2.
SELECT ALL THAT APPLY.
OFFICE AREA ......................................................................................... 01
STORE ..................................................................................................... 02
CLASSROOM .......................................................................................... 03
HOTEL OR MOTEL.................................................................................. 04
RESTAURANT ......................................................................................... 05
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S
HOME.................................................................................................... 06
HEALTHCARE FACILITY OR HOSPITAL................................................ 07
LABORATORY......................................................................................... 08
FACTORY, PLANT, OR PRODUCTION AREA........................................ 09
WAREHOUSE.......................................................................................... 10
GARAGE OR SHOP ................................................................................ 11
SALON ..................................................................................................... 12
LOADING DOCK...................................................................................... 13
CONSTRUCTION SITE............................................................................ 14
GROUNDS, YARD, OR GARDEN ........................................................... 15
MOTOR VEHICLE.................................................................................... 16
SOME OTHER LOCATION (SPECIFY): _________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OU030. What is the address where you actually {work/worked} at this job?
HOME....................................................................................................... 1
VARIES (CONSTRUCTION, LANDSCAPING) ........................................ 2
HAVE EXACT ADDRESS ........................................................................ 3
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(EL_OU02)
(EL_OU02)
(EL_OU02)
(EL_OU02)
(EL_OU02)
Appendix A
A.1.3.d–37
Version 1/20/08
Visit Type: T3
Target: Mother
OU031. (Please tell me the address where you actually {work/worked} at this job.)
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
END LOOP OU02
LOOP:
IF NUMBER OF CYCLES < TotalNumberOfJobsNew, CYCLE THROUGH BOX
OU04–OU031 AGAIN.
AFTER NUMBER OF CYCLES = TotalNumberOfJobsNew, CONTINUE WITH
OU032.
OU032. Now I want to ask about any cleaning products, chemicals, pesticides, radiation, or bacteria or viruses that you
may have worked around or used since {MONTH} at any job, school, or hobby.
When answering these questions, please consider all jobs, schools, and hobbies that you do for at least 4 hours
per week. Do not include regular household use.
BEGIN LOOP OU03
LOOP:
CYCLE THROUGH OU021–OU029 FOR CLEANING PRODUCTS, CHEMICALS,
PESTICIDES, DUSTS, FUMES, RADIATION, AND BACTERIA OR VIRUSES.
Appendix A
A.1.3.d–38
Version 1/20/08
Visit Type: T3
Target: Mother
OU033. (In any job, school, or hobby have you used or worked around:)
any {cleaning products, such as bleach, ammonia, or detergents/chemicals, such as paints, fuels, solvents, oils,
glues, or hair or nail products/pesticides that you’ve mixed or applied/dusts, including wood or mining dust/fumes
or gases, such as from anesthetic gases, ethylene oxide, welding or asphalt fumes, or engine exhaust/radiation,
including x-rays, fluoroscopy, or radioisotopes/bacteria or viruses, such as those used in a laboratory setting}?
(Again, do not include regular household use.)
PROBE: Only include activities that you do for 4 hours per week or longer.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_OU03)
REFUSED .......................................................................................... 9--97 (EL_OU03)
DON’T KNOW .................................................................................... 9--98 (EL_OU03)
OU034. Please tell me the name of (or describe) the {cleaning products/chemicals/pesticides/dusts/fumes or gases/
radiation/bacteria or viruses}?
_____________________________________________________
NAME OR DESCRIPTION OF EXPOSURE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU035. Do you handle or work directly with the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/
bacteria or viruses} or do you just work around it?
DON’T WORK DIRECTLY WITH THE MATERIAL .................................. 1
HANDLE DIRECTLY (POUR, TOUCH, ETC.) ......................................... 2
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OU036. Now thinking of the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/bacteria or viruses}
that you just mentioned….
OU037. Since {MONTH}, how often did you wear or use personal protective equipment to protect yourself from the
{cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/bacteria or viruses}? By personal
protective equipment, I mean things like gloves, dust masks, goggles, aprons, lab coats, or other protective
clothing. Would you say you always, often, rarely, or never use personal protective equipment?
ALWAYS .................................................................................................. 1
OFTEN ..................................................................................................... 2
RARELY ................................................................................................... 3
NEVER ..................................................................................................... 4 (OU4000)
REFUSED .......................................................................................... 9--97 (OU4000)
DON’T KNOW .................................................................................... 9--98 (OU4000)
Appendix A
A.1.3.d–39
Version 1/20/08
Visit Type: T3
Target: Mother
OU038. Please look at this card and tell me which types of protective clothing or equipment have you worn.
PROBE: Any other protective clothing or equipment?
SHOW CARD OU3.
SELECT ALL THAT APPLY.
GLOVES................................................................................................... 01
OVERALLS .............................................................................................. 02
OVERCOAT (E.G., LAB COAT, SMOCK, APRON) ................................. 03
DUST MASK ............................................................................................ 04
RESPIRATOR .......................................................................................... 05
GOGGLES/SAFETY GLASSES/FACE SHIELD ...................................... 06
WORK BOOTS/SHOES ........................................................................... 07
LEAD APRON .......................................................................................... 08
SOMETHING ELSE (SPECIFY): _______________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
ROUTING INSTRUCTION: IF OU038e = 05, CONTINUE. OTHERWISE, GO TO OU040.
OU039. What type of respirator was it?
A half-mask chemical cartridge respirator, which is silicone or rubber
and covers your mouth and nose, ............................................................ 1
A full-mask chemical cartridge respirator, which is silicone or rubber
and covers your eyes, nose, and mouth,.................................................. 2
An air-supplied or SCBA respirator, or .................................................... 3
Some other kind of respirator? (SPECIFY): _______________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OU040. Is there any kind of a ventilation system to remove exhaust, dust, smoke or fumes from the area? By ventilation
system we mean purposely opening windows or doors, using a fume hood, or other ventilation system.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_OU03)
REFUSED .......................................................................................... 9--97 (EL_OU03)
DON’T KNOW .................................................................................... 9--98 (EL_OU03)
Appendix A
A.1.3.d–40
Version 1/20/08
Visit Type: T3
Target: Mother
OU041. What ventilation systems are present to remove exhaust, dust, smoke or fumes from the area? Is there….
SELECT ALL THAT APPLY.
General ventilation, meaning open doors or windows, fans, etc............... 01
A regular ventilation system for building and room heating and cooling, .. 02
A fume hood, lab hood, or other partially enclosed equipment,................ 03
A glove box or other totally enclosed equipment, ..................................... 04
A portable exhaust hose or tube, such as those used for welding or to
attach to vehicle tailpipe, or ...................................................................... 05
Some other type of ventilation system? (SPECIFY): ________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP OU03
LOOP:
IF NUMBER OF CYCLES < 7 CYCLE AGAIN.
IF NUMBER OF CYCLES = 7, END LOOP AND CONTINUE WITH NEXT
SECTION.
Appendix A
A.1.3.d–41
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Perceived Stress
SD001. The following questions ask about your feelings and thoughts during the last month. Please look at this card and
tell me how often you felt or thought a certain way.
SD002. In the last month, how often have you been upset because of something that happened unexpectedly?
SHOW CARD SD1.
Never,....................................................................................................... 1
Almost never, ........................................................................................... 2
Sometimes, .............................................................................................. 3
Fairly often, or .......................................................................................... 4
Very often? ............................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD003. In the last month, how often have you felt that you were unable to control the important things in your life?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD004. (In the last month,) how often have you felt nervous and “stressed”?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–42
Version 1/20/08
Visit Type: T3
Target: Mother
SD005. (In the last month,) how often have you felt confident about your ability to handle your personal problems?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD006. (In the last month,) how often have you felt that things were going your way?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD007. (In the last month,) how often have you found that you could not cope with all the things that you had to do?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD008. (In the last month,) how often have you been able to control irritations in your life?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–43
Version 1/20/08
Visit Type: T3
Target: Mother
SD009. (In the last month,) how often have you felt you were on top of things?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD010. (In the last month,) how often have you been angered because of things that were outside of your control?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SD011. (In the last month,) how often have you felt difficulties were piling up so high that you could not overcome them?
SHOW CARD SD1.
NEVER ..................................................................................................... 1
ALMOST NEVER ..................................................................................... 2
SOMETIMES............................................................................................ 3
FAIRLY OFTEN........................................................................................ 4
VERY OFTEN .......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–44
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Maternal Depression
MD001. Since you are pregnant, we would like to know how you are feeling. Please tell me which answer choice comes
closest to how you have felt in the past 7 days, not just how you feel today.
MD002. Over the past 7 days, would you say you have been able to laugh and see the funny side of things:
As much as you always could, ................................................................. 1
Not quite as much now, ............................................................................ 2
Definitely not as much now, or ................................................................. 3
Not at all? ................................................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD003. Over the past 7 days, would you say you have looked forward with enjoyment to things:
As much ever, .......................................................................................... 1
Somewhat less than you used to, ............................................................ 2
Definitely less than you used to, or........................................................... 3
Hardly at all? ............................................................................................ 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD004. Over the past 7 days, would you say you have blamed yourself unnecessarily when things went wrong:
Most of the time,....................................................................................... 1
Some of the time, ..................................................................................... 2
Not very often, or...................................................................................... 3
Never?...................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD005. Would you say you have been anxious or worried for no good reason:
Not at all, .................................................................................................. 1
Hardly ever, .............................................................................................. 2
Sometimes, or .......................................................................................... 3
Very often? ............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD006. Would you say you have felt scared or panicky for no very good reason:
A lot, ......................................................................................................... 1
Sometimes, .............................................................................................. 2
Not much, or ............................................................................................ 3
Not at all? ................................................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–45
Version 1/20/08
Visit Type: T3
Target: Mother
MD007. Would you say you felt things have been getting on top of you:
Most of the time you haven’t been able to cope at all,.............................. 1
Sometimes you haven’t been coping as well as usual, ............................ 2
Most of the time you have coped quite well, or......................................... 3
You have been coping as well as ever? ................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD008. Would you say you have been so unhappy that you have had difficulty sleeping:
Most of the time,....................................................................................... 1
Sometimes, .............................................................................................. 2
Not very often, or...................................................................................... 3
Not at all? ................................................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD009. Would you say you have felt sad or miserable:
Most of the time,....................................................................................... 1
Quite often,............................................................................................... 2
Not very often, or...................................................................................... 3
Not at all? ................................................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD010. Would you say you have been so unhappy that you have been crying:
Most of the time,....................................................................................... 1
Quite often,............................................................................................... 2
Only occasionally, or ............................................................................... 3
Never?...................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD011. Would you say the thought of harming yourself has occurred to you:
Quite often,...............................................................................................
Sometimes, ..............................................................................................
Hardly ever, or .........................................................................................
Never?......................................................................................................
REFUSED ................................................................................................
DON’T KNOW ..........................................................................................
1
2
3
4
7
8
Appendix A
A.1.3.a–46
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Social Support
SS001. Next are some questions about the support that is available to you. For this section, please think about the time
since you became pregnant.
SS002. How many relatives do you have that you feel close to—people you feel comfortable with, can talk with about
personal things, or can ask for help if you need it? Include your husband, parents, children, and other relatives.
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
SS003. How many close friends do you have that you feel close to—people you feel comfortable with, can talk with
about personal things, or can ask for help if you need it?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
SS004. People sometimes look to others for companionship, assistance, or other types of support. Please refer to this
card and tell me how often you feel each of the following kinds of support has been available to you if you needed
it. Remember to think about how you have felt since you became pregnant.
SHOW CARD SS1.
SS005. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to help you if you were confined to bed.
SHOW CARD SS1.
Rarely or none of the time, ....................................................................... 1
A little of the time,..................................................................................... 2
Some of the time, ..................................................................................... 3
Most of the time, or................................................................................... 4
All of the time?.......................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–47
Version 1/20/08
Visit Type: T3
Target: Mother
SS006. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone you could count on to listen to you when you need to talk.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS007. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to give you good advice about a crisis.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS008. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to take you to the doctor if you needed it.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–48
Version 1/20/08
Visit Type: T3
Target: Mother
SS009. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone who shows you love and affection.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS010. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to have a good time with.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS011. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to give you information to help you understand a situation.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–49
Version 1/20/08
Visit Type: T3
Target: Mother
SS012. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to confide in or talk to about yourself or your problems.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS013. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone who hugs you.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS014. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to get together with for relaxation.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–50
Version 1/20/08
Visit Type: T3
Target: Mother
SS015. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to prepare your meals if you were unable to do it yourself.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS016. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone whose advice you really want.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS017. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to do things with, to help you get your mind off things.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–51
Version 1/20/08
Visit Type: T3
Target: Mother
SS018. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to help with daily chores if you were sick.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS019. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to share your most private worries and fears with.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS020. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to turn to for suggestions about how to deal with a personal problem.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–52
Version 1/20/08
Visit Type: T3
Target: Mother
SS021. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to do something enjoyable with.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS022. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone who understands your problems.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
SS023. (Please refer to this card and tell me how often you feel this kind of support has been available to you since you
became pregnant.)
Someone to love and make you feel wanted.
SHOW CARD SS1.
RARELY OR NONE OF THE TIME.......................................................... 1
A LITTLE OF THE TIME........................................................................... 2
SOME OF THE TIME ............................................................................... 3
MOST OF THE TIME ............................................................................... 4
ALL OF THE TIME ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–53
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Financial Security
FS001.
The next few questions are about whether you feel you have enough money for yourself and the people in your
house.
FS002. At this time, do you feel you are able to afford a home suitable for yourself and your family?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FS003. Do you feel you are able to afford the furniture or household equipment that you need?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FS004. Do you feel you are you able to afford the kind of car you need?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FS005. At this time, do you have enough money for the kind of food you think you and your family should have?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FS006. Do you have enough money for the kind of medical care you and your family should have?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FS007. At this time, do you have enough money for the kind of clothing you and your family should have?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–54
Version 1/20/08
Visit Type: T3
Target: Mother
FS008. Do you have enough money for the leisure activities you and your family want?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FS009. How difficult is it for you and your family to pay your bills? Would you say . . .
Very difficult,............................................................................................. 1
Somewhat difficult, ................................................................................... 2
Not very difficult, or................................................................................... 3
Not difficult at all? ..................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FS010. At the end of the month, how much money would you say you end up with?
Not enough money, .................................................................................. 1
Just enough money, ................................................................................. 2
Some money left over, or ......................................................................... 3
A lot of money left over?........................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FS011. Since you became pregnant, did you receive benefits from the WIC program, that is, the Women, Infants and
Children program?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FS012. Since you became pregnant, were you or any members of your household authorized to receive Food Stamps
(which includes a food stamp card or voucher, or cash grants from the state for food)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.d–55
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Sensitive Questions—ACASI
AI001.
These next questions may be somewhat sensitive. Like all of the other questions that you have answered today,
your response will be kept confidential. If you are not sure about an answer, give us your best estimate. If you’d
like you can listen to the questions using headphones and enter your information directly into the computer. You
can also listen to the questions without headphones or I can read the questions to you.
Which would you prefer? Would you like to:
Listen to the questions on your own using headphones, ..........................
Listen to the questions on your own without headphones, or ...................
Have me read the questions to you?........................................................
AI002.
1
2
3 (EOS)
As part of an earlier interview, you may have completed some questions like this on your own. Would you like to
do the practice questions this time, or would you like to go right ahead to the interview?
INTERVIEWER INSTRUCTIONS:
IF R WILL LISTEN TO QUESTIONS ON HER OWN (EITHER WITH OR WIHOUT HEADPHONES) THEN:
SET UP R SO THAT SHE IS SITTING DOWN IN FRONT OF THE COMPUTER SCREEN.
TURN SCREEN TOWARDS R AND ASSIST R WITH PRACTICE QUESTIONS.
DO PRACTICE QUESTIONS...................................................................
GO TO INTERVIEW .................................................................................
1
2
Appendix A
A.1.3.d–56
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Sensitive Questions—ACASI Practice
AP001. The first two 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.
AP002. What is your favorite soft drink?
RESPONDENT INSTRUCTION:
PLAY SOUND FILE AND DISPLAY TEXT: “Use the stylus to select your answer. Press ‘NEXT’ when you are
done.”
Coke .........................................................................................................
Pepsi ........................................................................................................
Sprite ........................................................................................................
7-Up .........................................................................................................
Another soft drink .....................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
5
9--97
9--98
AP003. During a typical week, how many movies do you watch?
|___|___|
NUMBER OF MOVIES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
AP004. 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.
Please put on the headphones now. Your interviewer will help you adjust the volume. When you are ready, press
“NEXT” to see the first question.
Appendix A
A.1.3.d–57
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Drugs, Alcohol, and Cigarette Use
DA001. Currently, do you smoke cigarettes or cigarillos?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (DA004)
9--97 (DA004)
9--98 (DA004)
DA002. Do you smoke cigarettes or cigarillos:
Every day .................................................................................................
5 or 6 days a week ...................................................................................
2–4 days a week ......................................................................................
Once a week ............................................................................................
1–3 days a month.....................................................................................
Less than once a month ...........................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06
9--97
9--98
DA003. On days that you smoke, how many cigarettes or cigarillos do you smoke per day? If you smoke 1 or less per
day, enter “1.”
|___|___|
NUMBER PER DAY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DA004. Currently, do you smoke or use any other tobacco products such as pipes, cigars, chewing tobacco, or snuff?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (DA007)
9--97 (DA007)
9--98 (DA007)
DA005. What do you use? You may select more than one answer.
Cigars .......................................................................................................
Pipes ........................................................................................................
Chewing tobacco......................................................................................
Snuff .........................................................................................................
Other .......................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
6
9--97
9--98
Appendix A
A.1.3.d–58
Version 1/20/08
Visit Type: T3
Target: Mother
DA006. Do you use the other tobacco products:
Every day .................................................................................................
5 or 6 days a week ...................................................................................
2–4 days a week ......................................................................................
Once a week ............................................................................................
1–3 days a month.....................................................................................
Less than once a month ...........................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06
9--97
9--98
DA007. Currently, do you use nicotine patches, nicotine gum, or other nicotine products?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (BOX DA01)
9--97 (BOX DA01)
9--98 (BOX DA01)
DA008. What do you use? You may select more than one answer.
Nicotine patches.......................................................................................
Nicotine gum ............................................................................................
Other nicotine product .............................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
6
9--97
9--98
DA009. Do you use the other nicotine products:
Every day .................................................................................................
5 or 6 days a week ...................................................................................
2–4 days a week ......................................................................................
Once a week ............................................................................................
1–3 days a month.....................................................................................
Less than once a month ...........................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06
9--97
9--98
DA010. On average, about how many hours per day do people smoke in the same room as you or near enough that you
can see or smell the smoke? Please consider all the places you are during the day, including at home, at work, or
some other place. If you are not exposed to smoke, enter “0.”
|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.d–59
Version 1/20/08
Visit Type: T3
Target: Mother
DA011. How often do you currently drink alcoholic beverages?
5 or more times a week ............................................................................
2–4 times a week .....................................................................................
Once a week ............................................................................................
1–3 times a month....................................................................................
Less than once a month ...........................................................................
Never........................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
01
02
03
04
05
06 (EOS)
9--97 (EOS)
9--98 (EOS)
DA012. Currently, on days that you drink alcoholic beverages how many did you have per day? If you drink 1 or less,
enter “1.”
|___|___|
NUMBER OF DRINKS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
DA013. Currently, how often do you have 5 or more drinks within a couple of hours:
Never........................................................................................................
About once a month .................................................................................
About once a week ...................................................................................
About once a day .....................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
9--97
9--98
DA014. Currently, on days that you drink alcoholic beverages, what type or types did you drink? You may select more
than one answer.
Wine .........................................................................................................
Beer..........................................................................................................
Hard Liquor/Mixed Drinks .........................................................................
Wine Coolers ...........................................................................................
Hard Lemonade/Hard Cider .....................................................................
Other ........................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
5
6
9--97
9--98
Appendix A
A.1.3.d–60
Version 1/20/08
Visit Type: T3
Target: Mother
T3 Visit: Domestic Abuse
AB001. The following questions are about your physical safety.
AB002. Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by anyone?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (AB008)
9--97 (AB008)
9--98 (AB008)
AB003. Was this by? You may select more than one answer.
Your husband or partner...........................................................................
Your parent...............................................................................................
Other adult family member .......................................................................
Someone you know, but not a family member..........................................
A stranger.................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
5
9--97
9--98
AB004. How often did this happen?
1 time........................................................................................................
2–3 times..................................................................................................
3 or more times ........................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
9--97
9--98
AB005. Since you’ve been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by anyone?
Yes ...........................................................................................................
No.............................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2 (AB008)
9--97 (AB008)
9--98 (AB008)
AB006. Was this by? You may select more than one answer.
Your husband or partner...........................................................................
Your parent...............................................................................................
Other adult family member .......................................................................
Someone you know, but not a family member..........................................
A stranger.................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
4
5
9--97
9--98
Appendix A
A.1.3.d–61
Version 1/20/08
Visit Type: T3
Target: Mother
AB007. How often has this happened?
1 time........................................................................................................
2–3 times..................................................................................................
3 or more times ........................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
9--97
9--98
AB008. Thank you for answering these questions. Please let your interviewer know that you are done.
Appendix A
A.1.3.e– 1
Version 1/20/08
Visit: 36 Week Phone
Target: Mother
Pregnancy Phone Follow-Up—T 36 Weeks
FZ001. I’ll begin by asking about how your pregnancy is progressing. We have your due date recorded as {DUE DATE}.
Is this still accurate?
YES .......................................................................................................... 1
NO, DATE IS DIFFERENT ....................................................................... 2
NO, PREGNANCY LOST ......................................................................... 3
NO, BABY ALREADY BORN ................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(FZ010)
(FZ006)
(FZ007)
(FZ010)
(FZ010)
FZ002. When was your baby born?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
FZ003. Sometimes babies who are born early need to spend extra time in the hospital before they can come home. Is
your baby in the hospital or is your baby home now?
BABY IS AT HOSPITAL ........................................................................... 1
BABY IS AT HOME .................................................................................. 2
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(FZ046)
(FZ046)
(FZ046)
(FZ046)
FZ004. At which hospital is your baby staying right now?
__________________________________________
HOSPITAL NAME
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (FZ046)
9--98 (FZ046)
Appendix A
A.1.3.e– 2
Version 1/20/08
Visit: 36 Week Phone
Target: Mother
FZ005. What is the address of the hospital?
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___| (FZ046)
ZIP CODE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (FZ046)
9--98 (FZ046)
FZ006. What is your new due date?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97 (FZ010)
9--98 (FZ010)
FZ007. I’m so sorry for your loss. I realize it may be difficult for you to talk about this, but it’s important for us to know
when {you lost the baby. Can you please tell me the date when it happened/your baby was born. What was the
date}?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
FZ008. Would it be alright if we sent you some information on how you can allow the study to request a copy of the
medical record for this loss?
YES ..........................................................................................................
NO ............................................................................................................
1
2
FZ009. DID RESPONDENT REQUEST ADDITIONAL INFORMATION ON COPING WITH PREGNANCY LOSS?
YES ..........................................................................................................
NO ............................................................................................................
1 (FZ045)
2 (FZ045)
FZ010. Do you plan on having a C-section to deliver your baby?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX FZ01)
REFUSED .......................................................................................... 9--97 (BOX FZ01)
DON’T KNOW .................................................................................... 9--98 (BOX FZ01)
Appendix A
A.1.3.e– 3
Version 1/20/08
Visit: 36 Week Phone
Target: Mother
FZ011. Have you scheduled a date to have the C-section?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX FZ01)
REFUSED .......................................................................................... 9--97 (BOX FZ01)
DON’T KNOW .................................................................................... 9--98 (BOX FZ01)
FZ012. What is that date?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX FZ01
CHECK ITEM:
IF NO PREGNANCY DIARY ENTRIES RECEIVED ACCORDING TO IMS AND
NO RECORD OF R REFUSING PREGNANCY DIARY IN IMS, CONTINUE WITH
FZ013.
IF RECORD OF R REFUSING PREGNANCY DIARY IN IMS, GO TO BOX FZ02.
IF ONLY SOME PREGNANCY DIARY ENTRIES RECEIVED ACCORDING TO
IMS, GO TO FZ015.
OTHERWISE, GO TO BOX FZ02.
FZ013. Are you using the Pregnancy Diary that we previously gave you? This is the diary where you record pregnancy
symptoms, such as spotting and nausea, and your intake of vitamins, painkillers, and specific foods.
YES .......................................................................................................... 1 (FZ015)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (FZ015)
DON’T KNOW .................................................................................... 9--98 (FZ015)
Appendix A
A.1.3.e– 4
Version 1/20/08
Visit: 36 Week Phone
Target: Mother
FZ014. Is that because…
You’ve misplaced the diary, or ................................................................. 1
You’ve forgotten to use it?........................................................................ 2
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(BOX FZ02)
(BOX FZ02)
(BOX FZ02)
(BOX FZ02)
(BOX FZ02)
FZ015. {Thank you for the diary entries that you’ve sent us. Having this information really improves the quality of the
NCS research.} We have not yet received your pregnancy diary entries for the week(s) of {DATES}. Because the
information is very important to the study, please send these entries in as soon as possible.
BOX FZ02
CHECK ITEM:
IF RECORD OF R REFUSING PREGNANCY MEDICAL CARE LOG IN IMS,
THEN GO TO BOX FZ03.
OTHERWISE, CONTINUE WITH FZ016.
FZ016. Are you using the Pregnancy Medical Care Log? This is the booklet that you or your doctor uses to record
information about your doctors visits.
YES .......................................................................................................... 1 (BOX FZ03)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (BOX FZ03)
DON’T KNOW .................................................................................... 9--98 (BOX FZ03)
FZ017. Is that because…
You haven’t had a medical visit since our last visit with you,.................... 1
You’ve misplaced the log, or .................................................................... 2
You’ve forgotten to bring it to your medical visits? ................................... 3
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.3.e– 5
Version 1/20/08
Visit: 36 Week Phone
Target: Mother
BOX FZ03
CHECK ITEM:
IF RESPONDENT LOST EITHER THE PREGNANCY DIARY (FZ014 CODED “1”)
OR THE MEDICAL PROVIDER LOG (FZ017 CODED “2”) GO TO FZ018.
IF RESPONDENT REFUSED EITHER THE PREGNANCY DIARY OR THE
MEDICAL CARE PROVIDER LOG, GO TO FZ020.
IF RESPONDENT NOT USING PREGNANCY DIARY FOR ANY REASON
OTHER THAN LOSS (FZ014 CODED “2” OR “6”–“8”) OR NOT USING MED LOG
FOR ANY REASON OTHER THAN LOSS OR NO MEDICAL VISITS (FZ017
CODED “3” OR “6”–“8”), GO TO FZ019.
OTHERWISE, GO TO FZ020.
FZ018. We’ll get another {Pregnancy Diary/{and} Pregnancy Medical Care Log} in the mail to you today.
FZ019. This information is very important to the study. Please keep the {log/{and the} diary} in a safe place {and
remember to {fill out the diary at the same time every week/{and} bring the log with you to any medical visit}}.
FZ020. I am now going to ask about visits to a doctor or other health care provider. Please include routine prenatal visits,
visits for sonograms, an amniocentesis, and other pregnancy-related tests and procedures, as well as any other
visits to a doctor or other health care provider either at a clinic, doctor’s office or HMO, emergency room, or
hospital outpatient department. Please refer to {the Pregnancy Medical Care Log that you received as part of this
study or to} any {other} personal record or calendar that you keep that would help you to remember the dates of
these visits. {I’ll be asking you to put a checkmark in the box next to each visit once you’ve finished telling me
about it.} If you have this information available, please go and get it now.
FZ021. {Since you became pregnant/Since {MONTH}} have you seen a doctor or heath care provider for any reason?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (FZ044)
REFUSED .......................................................................................... 9--97 (FZ044)
DON’T KNOW .................................................................................... 9--98 (FZ044)
BEGIN LOOP FZ01
LOOP:
CYCLE THROUGH FZ022–FZ024 FOR EACH VISIT TO A DOCTOR OR OTHER
HEALTH CARE PROVIDER.
FZ022. {Beginning with the most recent visit, please give me the date of the visit. Please give me the date of the next
most recent visit.}
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.3.e– 6
Version 1/20/08
Visit: 36 Week Phone
Target: Mother
FZ023. What kind of place did you go to—a clinic or health center, doctor’s office or HMO, a hospital emergency room, a
hospital outpatient department, or some other place?
CLINIC OR HEALTH CENTER ................................................................ 1
DOCTOR’S OFFICE OR HMO................................................................. 2
HOSPITAL EMERGENCY ROOM ........................................................... 3
HOSPITAL OUTPATIENT DEPARTMENT .............................................. 4
SOME OTHER PLACE (SPECIFY):_____________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FZ024. What was the main reason for the visit?
Prenatal care (including sonograms, amniocentesis, or other pregnancyrelated procedures), .............................................................................. 1
Physical, ................................................................................................... 2
Sick visit, or .............................................................................................. 3
Some other reason? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(FZ031)
(FZ031)
(FZ031)
(FZ031)
(FZ031)
FZ025. At this visit, what was your weight?
WEIGHT MEASURED..............................................................................
WEIGHT NOT MEASURED .....................................................................
1
2 (FZ027)
FZ026. (At this visit, what was your weight?)
|___|___|___|.|___|
WEIGHT
POUNDS ..................................................................................................
KILOGRAMS ............................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
9--97
9--98
FZ027. At this visit, what was your blood pressure?
BLOOD PRESSURE MEASURED...........................................................
BLOOD PRESSURE NOT MEASURED ..................................................
1
2 (FZ030)
Appendix A
A.1.3.e– 7
Version 1/20/08
Visit: 36 Week Phone
Target: Mother
FZ028. (At this visit, what was your blood pressure?)
INTERVIEWER INSTRUCTION:
BOTH SYSTOLIC AND DIASTOLIC MUST BE ENTERED. IF ONE OR BOTH ARE UNKNOWN, SELECT DK.
|___|___|___|
SYSTOLIC BLOOD PRESSURE
|___|___|___|
DIASTOLIC BLOOD PRESSURE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX FZ05
CHECK ITEM:
IF FZ028 = “RF” OR “DK,” CONTINUE WITH FZ029.
OTHERWISE, GO TO FZ030.
FZ029. Was it normal, high or low?
NORMAL .................................................................................................. 1
HIGH ........................................................................................................ 2
LOW ......................................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FZ030. At this visit, were any of the following procedures performed?
a.
b.
c.
d.
Ultrasound? ........................................................................................
Amniocentesis? ..................................................................................
CVS (Chorionic Villi Sampling)? .........................................................
Other test or procedure? (SPECIFY):_________________________
YES
1
1
1
1
NO
2
2
2
2
RF
9--97
9--97
9--97
9--97
DK
9--98
9--98
9--98
9--98
FZ031. Did a doctor or other health care provider give you a diagnosis or tell you that you had any illness or other medical
condition?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (FZ033)
REFUSED .......................................................................................... 9--97 (FZ033)
DON’T KNOW .................................................................................... 9--98 (FZ033)
Appendix A
A.1.3.e– 8
Version 1/20/08
Visit: 36 Week Phone
Target: Mother
FZ032. What was the diagnosis?
SELECT ALL THAT APPLY.
ANEMIA.................................................................................................... 01
BACTERIAL VAGINOSIS......................................................................... 02
EARLY OR PREMATURE LABOR........................................................... 03
GESTATIONAL DIABETES...................................................................... 04
GROUP B STREP .................................................................................... 05
HERPES................................................................................................... 06
HIGH BLOOD PRESSURE ...................................................................... 07
ISOIMMUNIZATION................................................................................. 08
PELVIC INFLAMMATORY DISEASE (PID) ............................................. 09
PREECLAMPSIA ..................................................................................... 10
PROTEIN IN YOUR URINE ..................................................................... 11
RH DISEASE............................................................................................ 12
TOXEMIA ................................................................................................. 13
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FZ033. Did you receive any vaccinations at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (FZ035)
REFUSED .......................................................................................... 9--97 (FZ035)
DON’T KNOW .................................................................................... 9--98 (FZ035)
FZ034. What did you receive?
SELECT ALL THAT APPLY.
FLU/ NFLUENZA...................................................................................... 1
HEPATITIS B ........................................................................................... 2
TETANUS/DIPHTHERIA .......................................................................... 3
MENINGOCOCCAL ................................................................................. 4
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FZ035. {If you haven’t yet, please put a checkmark in the box next to the visit you just told me about in your Pregnancy
Medical Care Log.}
Have you had any other visits to a doctor or other health care provider {since you became pregnant/since
{MONTH}}? Please include routine prenatal visits, as well as visits to a doctor or other health care provider either
at a clinic, doctor’s office or HMO, emergency room, or outpatient department for any other reason.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_FZ01)
REFUSED .......................................................................................... 9--97 (EL_FZ01)
DON’T KNOW .................................................................................... 9--98 (EL_FZ01)
Appendix A
A.1.3.e– 9
Version 1/20/08
Visit: 36 Week Phone
Target: Mother
END LOOP FZ01
LOOP:
IF FZ035 = “1,” CYCLE AGAIN.
OTHERWISE, END LOOP AND CONTINUE WITH FZ036.
FZ036. {Since you became pregnant/Since {MONTH}} have you spent at least one night in the hospital?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (FZ044)
REFUSED .......................................................................................... 9--97 (FZ044)
DON’T KNOW .................................................................................... 9--98 (FZ044)
BEGIN LOOP FZ02
LOOP:
CYCLE THROUGH FZ037–FZ043 FOR EACH HOSPITALIZATION.
FZ037. What was the admission date of your {next} most recent hospitalization?
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
FZ038. How many nights did you stay at the hospital during this hospitalization?
|___|___|___|
NUMBER OF NIGHTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
FZ039. Did a doctor or other health care provider give you a diagnosis while you were hospitalized?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (FZ041)
REFUSED .......................................................................................... 9--97 (FZ041)
DON’T KNOW .................................................................................... 9--98 (FZ041)
Appendix A
A.1.3.e– 10
Version 1/20/08
Visit: 36 Week Phone
Target: Mother
FZ040. What was the diagnosis?
SELECT ALL THAT APPLY.
DEHYDRATION ....................................................................................... 01
PRETERM LABOR................................................................................... 02
HYPEREMISIS......................................................................................... 03
PREECLAMPISA ..................................................................................... 04
RUPTURE OF MEMBRANES .................................................................. 05
KIDNEY DISORDER ................................................................................ 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
FZ041. Did you receive any treatments while you were hospitalized? Please include any vaccinations you may have
received.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (FZ043)
REFUSED .......................................................................................... 9--97 (FZ043)
DON’T KNOW .................................................................................... 9--98 (FZ043)
FZ042. What treatments did you receive?
_____________________________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
FZ043. {If you haven’t yet, please put a checkmark in the box next to the visit you just told me about in your Pregnancy
Medical Care Log.}
Have you had any other hospitalizations {since you became pregnant/since {MONTH}}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP FZ02
LOOP:
IF FZ043 = “1,” CYCLE AGAIN.
OTHERWISE, CONTINUE WITH FZ044.
Appendix A
A.1.3.e– 11
Version 1/20/08
Visit: 36 Week Phone
Target: Mother
FZ044. These are all the questions I have at this time. {We’ll send another {Pregnancy Diary} {and} {Medical Care
Provider Log} in the mail right away.} {Please remember to use the Pregnancy Diary and to bring the Pregnancy
Medical Care Log with you to any doctor’s visits you may have until your baby is born.}
As was previously mentioned, it is important for the study center to know when you go into labor. INSERT VC/SC
SPECIFIC PROCEDURES HERE. Thank you for your time.
BOX FZ06
CHECK ITEM:
GO TO EOS.
FZ045. Again, I’d like to say how sorry I am for your loss. {We’ll send the information packet you requested as soon as
possible.} Please accept our best wishes for a quick recovery. {We’ll call you again in a few months to see how
you’re doing.} Thank you for your time.
BOX FZ07
CHECK ITEM:
GO TO EOS.
FZ046. It is important to the study that we collect information soon after birth for all babies. We know that the time after
the birth of a new baby can be very busy. [NAME OF VC COORDINATOR] who has spoken with you before will
be calling you shortly to set up an appointment to get some information on how your baby is doing. Thanks so
much for your time and best wishes as your family adjusts to its new arrival.
Appendix A
A.1.4.a–1
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
3-Month Phone Call
TC0100. I’m calling today just to gather some information about you and {CHILD}.
TC0200. I’ll begin by asking you about {CHILD}’s sleeping habits.
TC0300. Does your baby usually sleep in your bedroom or in a different room at night?
IN RESPONDENT’S ROOM .................................................................... 1
IN A DIFFERENT ROOM ......................................................................... 2
BOTH IN RESPONDENT’S ROOM AND A DIFFERENT ROOM............. 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC0400. What does your baby sleep in at night?
A bassinette, ............................................................................................ 1
A crib, ....................................................................................................... 2
A co-sleeper, ............................................................................................ 3
In the bed or other place with you, or ....................................................... 4
In something else? (SPECIFY): ________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC0500. In what position do you most often lay the baby down to sleep at night? On their..
Side, ........................................................................................................ 1
Stomach, or .............................................................................................. 2
Back? ....................................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC0600. Approximately how many hours does your baby sleep during the day?
|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC0700. Approximately how many hours does your baby sleep at night?
|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.a–2
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC0800. How often is your baby difficult when {he/she} is put to bed?
Most of the time,....................................................................................... 1
Often, ....................................................................................................... 2
Sometimes, .............................................................................................. 3
Rarely, or.................................................................................................. 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC0900. All babies fuss and cry sometimes. I’m now going to ask you some questions to get a better idea of your baby’s
crying patterns.
TC1000. Compared to other babies, do you think your baby cries more, the same or less?
MORE....................................................................................................... 1
THE SAME ............................................................................................... 2
LESS ........................................................................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC1100. Can you usually calm or console your baby when {he/she} cries?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC1200. Does your baby have episodes of colic, or times when {he/she} cries and can’t be calmed or consoled?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC1800)
REFUSED .......................................................................................... 9--97 (TC1800)
DON’T KNOW .................................................................................... 9--98 (TC1800)
TC1300. How often does your baby have episodes of colic, or times when {he/she} cries and can’t be calmed or consoled:
Every day, ................................................................................................ 1
Most days, ................................................................................................ 2
Sometimes, or .......................................................................................... 3
Rarely? ..................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.a–3
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC1400. During these episodes, can you give me some idea of how much time your baby has usually spent fussing and
crying in the morning between 6 am and noon?
|___|___|
HOURS
|___|___|
MINUTES
NO USUAL PATTERN .......................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91
9--97
9--98
TC1500. How about in the afternoon, between noon and 6 pm?
|___|___|
HOURS
|___|___|
MINUTES
NO USUAL PATTERN .......................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91
9--97
9--98
TC1600. How about in the evening, between 6 pm and midnight?
|___|___|
HOURS
|___|___|
MINUTES
NO USUAL PATTERN .......................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91
9--97
9--98
TC1700. How about at night, between midnight and 6 am?
|___|___|
HOURS
|___|___|
MINUTES
NO USUAL PATTERN .......................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91
9--97
9--98
Appendix A
A.1.4.a–4
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC1800. I will read a list of methods used to settle and soothe babies. Tell me which, if any, you have used to settle your
baby in the last week.
SELECT ALL THAT APPLY.
Cuddling and rocking,............................................................................... 1
Swaddling,................................................................................................ 2
Car rides,.................................................................................................. 3
Singing or soothing sounds of music, ....................................................... 4
Extra feeding or drinks,............................................................................. 5
Non-prescribed medicines........................................................................ 6
Prescribed medicines ............................................................................... 7
Let them cry, or ........................................................................................ 8
Another method? (SPECIFY): _________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC1900. Are you finding your baby’s crying to be a problem or upsetting?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC2000. Even though your baby is only 3 months old, {he/she} may show emotions or other actions. Overall, would you
describe your baby as…
YES
NO
RF
DK
a.
b.
c.
d.
e.
f.
g.
Calm ...................................................................................................
Worried? .............................................................................................
Sociable or outgoing? .........................................................................
Angry? ................................................................................................
Shy or quiet? ......................................................................................
Stubborn? ...........................................................................................
Happy? ...............................................................................................
1
1
1
1
1
1
1
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
Appendix A
A.1.4.a–5
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC2100. I will read you a list of things your baby may already do or may start doing when {he/she} gets older. Does your
baby…
YES
NO
RF
DK
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9—98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
Look at your face when you hold or feed {him/her}? ................................
Follow you with {his/her} eyes? ................................................................
Smile when you smile at {him/her}? .........................................................
Smile by {himself/herself}? .......................................................................
Laugh or squeal?......................................................................................
Lift {his/her} head when lying on stomach? ..............................................
Startle or react to a sound? ......................................................................
Try to get a toy that is out of reach? .........................................................
Reaches for toys or food held to him/her?................................................
Startle or react to a sound? ......................................................................
Turns towards a sound? ...........................................................................
Turns toward someone when they’re speaking? ......................................
Makes sounds as though he/she is trying to speak? ................................
Can keep head steady when sitting or held up?.......................................
Rolls over from stomach to back? ............................................................
Rolls from back to stomach? ....................................................................
TC2300. Next, I’d like to ask you about different types of child care {CHILD} may receive from someone other than parents
or guardians. This includes regularly scheduled care arrangements with relatives and non-relatives, and day care
or early childhood programs, whether or not there is a charge or fee, but not occasional baby-sitting.
TC2400. Does {CHILD} currently receive any regularly scheduled care from someone other than a parent or guardian, for
example from relatives, non-relatives, or a child care center or program?
Yes ........................................................................................................... 1
No............................................................................................................. 2 (TC2800)
REFUSED .......................................................................................... 9--97 (TC2800)
DON’T KNOW .................................................................................... 9--98 (TC2800)
TC2500. I’d like you to think about all the care {CHILD} receives from relatives, for example, from grandparents, brothers or
sisters, or any other relatives. This includes all regularly scheduled care arrangements with relatives that happen
at least weekly, but does not include occasional baby-sitting. Including all of these regular arrangements, how
many total hours each week does {CHILD} receive care from relatives?
|___|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.a–6
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC2600. I’d like you to think about all the regularly scheduled care your child receives on a weekly basis from non-relatives
in a home setting. This includes all regularly scheduled care arrangements with non-relatives that happen at least
weekly, including home child care providers, regularly scheduled sitter arrangements, or neighbors. This does not
include day care centers, early childhood programs, or occasional babysitting. Including all of these
arrangements, how many total hours each week does {CHILD} receive care from non-relatives in a home setting?
|___|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC2700. I’d like you to think about all the care your child receives from child care centers. For example, day care centers,
early learning centers, nursery schools, and preschools. This includes all regularly scheduled care arrangements
in child care centers that happen at least weekly. Including all of these arrangements, how many total hours each
week does {CHILD} receive care at child care centers?
|___|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC2800. Since {{CHILD} was born/{MONTH}}, would you say {CHILD’s} health has been poor, fair, good, excellent?
POOR....................................................................................................... 1
FAIR ......................................................................................................... 2
GOOD ...................................................................................................... 3
EXCELLENT ............................................................................................ 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC2900. Are you using the Infant Medical Care Log? This is the booklet that you or your doctor uses to record information
about your child’s doctor visits.
YES .......................................................................................................... 1 (BOX TC01)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (BOX TC01)
DON’T KNOW .................................................................................... 9--98 (BOX TC01)
TC3000. Is that because…
You haven’t had a medical visit since our last visit with you,.................... 1
You’ve misplaced the log, or .................................................................... 2
You’ve forgotten to bring it to your medical visits? ................................... 3
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.a–7
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
BOX TC01
CHECK ITEM:
IF RESPONDENT LOST THE INFANT MEDICAL CARE LOG (TC3000 = “2”)
CONTINUE WITH TC3100.
IF RESPONDENT REFUSED INFANT MEDICAL CARE PROVIDER LOG, GO
TO TC3300.
IF RESPONDENT NOT USING INFANT MEDICAL CARE LOG FOR ANY
REASON OTHER THAN LOSS OR NO MEDICAL VISITS (TC3000) IN
(“3”,”6”,”7”,”8”), GO TO TC3200.
OTHERWISE, GO TO TC3300.
TC3100. We’ll get another Infant Medical Care Log in the mail to you today.
TC3200. This information is very important to the study. Please keep the log in a safe place and bring the log with you to all
of your child’s medical visits.
TC3300. I am now going to ask some questions about your child’s visits to a doctor or other health care provider. After that,
I will ask about your last few visits to a doctor or other health provider before you gave birth.
Please include routine well visits, sick visits, and any other visits to a doctor or other health care provider at a
clinic, doctor’s office or HMO, emergency room, or hospital outpatient department.
Please refer to the Infant Medical Care Log and Pregnancy Medical Care Log that you received as part of this
study or to any other personal record or calendar that you keep that would help you to remember the dates of
these visits. I’ll be asking you to put a check mark in the box next to each visit once you’ve finished telling me
about it.
If you have the medical care logs available, please go and get them now.
TC3400. Since your baby was born, has {CHILD} seen a doctor or heath care provider for any reason?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX TC02)
REFUSED .......................................................................................... 9--97 (BOX TC02)
DON’T KNOW .................................................................................... 9--98 (BOX TC02)
BEGIN LOOP TC01
LOOP:
CYCLE THROUGH TC3500–TC5000 FOR EACH VISIT TO A DOCTOR OR
OTHER HEALTH CARE PROVIDER.
Appendix A
A.1.4.a–8
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC3500. {Beginning with the most recent visit, please give me the date of the visit/Please give me the date of the next most
recent visit.}
INTERVIEWER INSTRUCTION:
ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR.
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC3600. What kind of place did you take your child to – a clinic or health center, doctor’s office or HMO, a hospital
emergency room, a hospital outpatient department, or some other place?
CLINIC OR HEALTH CENTER ................................................................ 1
DOCTOR’S OFFICE OR HMO................................................................. 2
HOSPITAL EMERGENCY ROOM ........................................................... 3
HOSPITAL OUTPATIENT DEPARTMENT .............................................. 4
SOME OTHER PLACE (SPECIFY):_____________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC3700. What was the main reason for the visit?
Routine well visit,...................................................................................... 1
Sick visit, or .............................................................................................. 3
Some other reason? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(TC4600)
(TC4600)
(TC4600)
(TC4600)
TC3800. At this visit, what was your child’s weight?
WEIGHT MEASURED..............................................................................
WEIGHT NOT MEASURED .....................................................................
1
2 (TC4000)
TC3900. (At this visit, what was your child’s weight?)
|___|___|
POUNDS
OR
|___|___|.|__|
KILOGRAMS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.a–9
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC4000. At this visit, what was your child’s length?
LENGTH/HEIGHT MEASURED ...............................................................
LENGTH/HEIGHT NOT MEASURED ......................................................
1
2 (TC4200)
TC4100. (At this visit, what was your child’s length?)
|___|___|.|__|
INCHES
OR
|___|___|.|__|
CENTIMETERS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC4200. At this visit, what was your child’s head circumference?
HEAD CIRCUMFERENCE MEASURED..................................................
HEAD CIRCUMFERENCE NOT MEASURED .........................................
1
2 (TC4400)
TC4300. (At this visit, what was your child’s head circumference?)
|___|___|.|__|
INCHES
OR
|___|___|.|__|
CENTIMETERS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC4400. Did your child receive any vaccinations at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC4600)
REFUSED .......................................................................................... 9--97 (TC4600)
DON’T KNOW .................................................................................... 9--98 (TC4600)
Appendix A
A.1.4.a–10
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC4500. What did {he/she} receive? What was the lot number for the vaccine your child received?
RECEIVED
YES
NO
Hepatitis B ................................................................................................
Diphtheria, Tetanus, and Pertussis (DTaP) ..............................................
H. Influenza Type B (Hib) .........................................................................
Inactivated Polio (IPV) ..............................................................................
Pneumococcal Conjugate (PCV7)............................................................
Measles, Mumps, and Rubella (German measles)...................................
Varicella (Chickenpox) .............................................................................
Hepatitis A ................................................................................................
Influenza...................................................................................................
Rotavirus ..................................................................................................
Meningococcal .........................................................................................
Other (SPECIFY):___________________________________________
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
TC4600. Did a doctor or other health care provider give your child a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC4800)
REFUSED .......................................................................................... 9--97 (TC4800)
DON’T KNOW .................................................................................... 9--98 (TC4800)
TC4700. What was the diagnosis?
INTERVIEWER INSTRUCTION:
ENTER ALL DIAGNOSES IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
DIAGNOSES
REFUSED ................................................................................................ 9--97
DON’T KNOW .......................................................................................... 9--98
TC4800. Did your child receive any treatments at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC5000)
REFUSED .......................................................................................... 9--97 (TC5000)
DON’T KNOW .................................................................................... 9--98 (TC5000)
LOT NUMBER
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Appendix A
A.1.4.a–11
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC4900. What treatments did {he/she} receive?
INTERVIEWER INSTRUCTION:
ENTER ALL TREATMENTS IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC5000. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Infant Medical
Care Log. Has your child had any other visits to a doctor or other health care provider since {he/she} was born?
Please include routine well visits, as well as visits to a doctor or other health care provider either at a clinic,
doctor’s office or HMO, emergency room, or outpatient department for any other reason.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_TC01)
REFUSED .......................................................................................... 9--97 (EL_TC01)
DON’T KNOW .................................................................................... 9--98 (EL_TC01)
END LOOP TC01
LOOP:
IF TC5000 = “1”, CYCLE AGAIN.
OTHERWISE, END LOOP AND CONTINUE WITH TC5100.
TC5100. After coming home from the hospital the first time, has your child spent at least one night in the hospital?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC5900)
REFUSED .......................................................................................... 9--97 (TC5900)
DON’T KNOW .................................................................................... 9--98 (TC5900)
BEGIN LOOP TC02
LOOP:
CYCLE THROUGH TC5200–TC5800 FOR EACH HOSPITALIZATION.
TC5200. What was the admission date of your child’s {next} most recent hospitalization?
INTERVIEWER INSTRUCTION:
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR.
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.a–12
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC5300. How many nights did your child stay at the hospital during this hospitalization?
|___|___|___|
NUMBER OF NIGHTS
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9—98
TARGET: 3 MONTH, 6 MONTH, 9 MONTH, 12 MONTH, 18 MONTH, 24 MONTH
SOFT EDIT: IF > 14.
TC5400. Did a doctor or other health care provider give your child a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC5600)
REFUSED .......................................................................................... 9--97 (TC5600)
DON’T KNOW .................................................................................... 9--98 (TC5600)
TC5500. What was the diagnosis?
INTERVIEWER INSTRUCTION:
ENTER ALL DIAGNOSES IN FIELD SEPARATED BY COMMAS OR AN “AND”.
________________________________
DIAGNOSES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC5600. Did your child receive any treatments? Please include any vaccinations your child may have received.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC5800)
REFUSED .......................................................................................... 9--97 (TC5800)
DON’T KNOW .................................................................................... 9--98 (TC5800)
TC5700. What treatments did your child receive?
INTERVIEWER INSTRUCTION:
ENTER ALL TREATMENTS IN FIELD SEPARATED BY COMMAS OR AN “AND”.
________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.a–13
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC5800. If you haven’t yet, put a check mark in the box next to the visit that you just told me about in your Infant Medical
Care Log. Has your child had any other hospitalizations since coming home from the hospital the first time?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP TC02
LOOP:
IF TC5800 = “1,” CYCLE AGAIN.
OTHERWISE, CONTINUE TC5900.
BOX TC02
CHECK ITEM:
IF 3 MONTH, CONTINUE.
IF 9 MONTH, GO TO BOX TC06.
TC5900. Now let’s talk about your last few visits to a doctor or other health care provider up until you gave birth.
Please refer to your Pregnancy Medical Care Log if you have it available.
TC6000. Since {MONTH} have you seen a doctor or heath care provider for any reason?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC8400)
REFUSED .......................................................................................... 9--97 (TC8400)
DON’T KNOW .................................................................................... 9--98 (TC8400)
BEGIN LOOP TC03
LOOP:
CYCLE THROUGH TC6100–TC7400 FOR EACH VISIT TO A DOCTOR OR
OTHER HEALTH CARE PROVIDER.
TC6100. {Beginning with the most recent visit, please give me the date of the visit/Please give me the date of the next most
recent visit.}
INTERVIEWER INSTRUCTION:
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR.
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.a–14
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC6200. What kind of place did you go to—a clinic or health center, doctor’s office or HMO, a hospital emergency room, a
hospital outpatient department, or some other place?
CLINIC OR HEALTH CENTER ................................................................ 1
DOCTOR’S OFFICE OR HMO................................................................. 2
HOSPITAL EMERGENCY ROOM ........................................................... 3
HOSPITAL OUTPATIENT DEPARTMENT .............................................. 4
SOME OTHER PLACE (SPECIFY):_____________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC6300. What was the main reason for the visit?
Prenatal care (including sonograms or ultrasounds, amniocentesis,
or other pregnancy related procedures), ............................................... 1
Physical, ................................................................................................... 2
Sick visit, or .............................................................................................. 3
Some other reason? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(TC7000)
(TC7000)
(TC7000)
(TC7000)
(TC7000)
TC6400. At this visit, what was your weight?
WEIGHT MEASURED..............................................................................
WEIGHT NOT MEASURED .....................................................................
1
2 (TC6600)
TC6500. (At this visit, what was your weight?)
|___|___|
POUNDS
OR
|___|___|___|.|__|
KILOGRAMS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC6600. At this visit, what was your blood pressure?
BLOOD PRESSURE MEASURED...........................................................
BLOOD PRESSURE NOT MEASURED ..................................................
1
2 (TC6800)
Appendix A
A.1.4.a–15
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC6700. (At this visit, what was your blood pressure?)
INTERVIEWER INSTRUCTION:
BOTH SYSTOLIC AND DIASTOLIC MUST BE ENTERED. IF ONE OR BOTH ARE UNKNOWN, SELECT DK.
|___|___|___|
SYSTOLIC BLOOD PRESSURE
|___|___|___|
DIASTOLIC BLOOD PRESSURE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX TC03
CHECK ITEM:
IF TC6700 = “9--97” OR “9—98,” CONTINUE WITH TC6800.
OTHERWISE, GO TO TC6900.
TC6800. Was it normal, high or low?
NORMAL .................................................................................................. 1
HIGH ........................................................................................................ 2
LOW ......................................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC6900. At this visit, were any of the following procedures performed?
a.
b.
c.
d.
Ultrasound or sonogram? ...................................................................
Amniocentesis? ..................................................................................
CVS (Chorionic Villi Sampling)? .........................................................
Any other test or procedure? (SPECIFY): _____________________
YES
NO
RF
DK
1
1
1
1
2
2
2
2
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
HELP SCREEN:
Ultrasound/Sonogram: An ultrasound is done during pregnancy to produce pictures of the baby before birth.
These pictures are produced by a special probe moved over your abdomen or placed in your vagina. The pictures
can be viewed on a screen and copies may be made and given to you or stored in your baby’s medical record.
Amniocentesis: Refers to a procedure in which a needle is inserted through the abdomen into the uterus to
withdraw a small amount of amniotic fluid and fetal cells. Amniocentesis is done to look for certain types of birth
defects and is typically performed after 14 weeks gestation.
CVS: CVS is a procedure in which a small sample of cells is taken from the placenta. Cells can be collected either
through the vagina, using a small plastic tube, or through the abdomen, using a slender needle. CVS is used to
detect birth defects, genetic diseases and other problems and is usually done between 10 weeks gestation and
the end of the first trimester.
Appendix A
A.1.4.a–16
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
BOX TC04
CHECK ITEM:
IF TC6300 = “1,” GO TO TC7400.
OTHERWISE, CONTINUE WITH TC7000.
TC7000. Did a doctor or other health care provider give you a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC7200)
REFUSED .......................................................................................... 9--97 (TC7200)
DON’T KNOW .................................................................................... 9--98 (TC7200)
TC7100. What was the diagnosis?
SELECT ALL THAT APPLY.
ANEMIA.................................................................................................... 01
BACTERIAL VAGINOSIS......................................................................... 02
EARLY OR PREMATURE LABOR........................................................... 03
GESTATIONAL DIABETES...................................................................... 04
GROUP B STREP .................................................................................... 05
HERPES................................................................................................... 06
HIGH BLOOD PRESSURE ...................................................................... 07
ISOIMMUNIZATION................................................................................. 08
PELVIC INFLAMMATORY DISEASE (PID) ............................................. 09
PREECLAMPSIA ..................................................................................... 10
PROTEIN IN YOUR URINE ..................................................................... 11
RH DISEASE............................................................................................ 12
TOXEMIA ................................................................................................. 13
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC7200. Did you receive any vaccinations at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC7400)
REFUSED .......................................................................................... 9--97 (TC7400)
DON’T KNOW .................................................................................... 9--98 (TC7400)
Appendix A
A.1.4.a–17
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC7300. What did you receive?
SELECT ALL THAT APPLY.
FLU/INFLUENZA...................................................................................... 1
HEPATITIS B ........................................................................................... 2
TETANUS/DIPHTHERIA .......................................................................... 3
MENINGOCOCCAL ................................................................................. 4
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC7400. {If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Pregnancy
Medical Care Log.} Have you had any other visits to a doctor or other health care provider since {MONTH}?
Please include routine prenatal visits, as well as visits to a doctor or other health care provider either at a clinic,
doctor’s office or HMO, emergency room, or outpatient department for any other reason.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_TC03)
REFUSED .......................................................................................... 9--97 (EL_TC03)
DON’T KNOW .................................................................................... 9--98 (EL_TC03)
END LOOP TC03
LOOP:
IF TC7400 = “1”, CYCLE AGAIN.
OTHERWISE, END LOOP AND CONTINUE WITH TC7500.
TC7500. Since {MONTH} have you spent at least one night in the hospital?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC8400)
REFUSED .......................................................................................... 9--97 (TC8400)
DON’T KNOW .................................................................................... 9--98 (TC8400)
BEGIN LOOP TC04
LOOP:
CYCLE THROUGH TC7600-TC8300 FOR EACH HOSPITALIZATION.
Appendix A
A.1.4.a–18
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC7700. What was the admission date of your {next} most recent hospitalization?
INTERVIEWER INSTRUCTION:
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR.
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC7800. How many nights did you stay at the hospital during this hospitalization?
|___|___|___|
NUMBER OF NIGHTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC7900. Did a doctor or other health care provider give you a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC8100)
REFUSED .......................................................................................... 9--97 (TC8100)
DON’T KNOW .................................................................................... 9--98 (TC8100)
TC8000. What was the diagnosis?
SELECT ALL THAT APPLY.
DEHYDRATION ....................................................................................... 01
PRETERM LABOR................................................................................... 02
HYPEREMESIS ....................................................................................... 03
PREECLAMPSIA ..................................................................................... 04
RUPTURE OF MEMBRANES .................................................................. 05
KIDNEY DISORDER ................................................................................ 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HELP SCREEN:
Dehydration: Dehydration occurs when the body loses more water than it takes in. In pregnancy, severe vomiting
and decreased water intake can lead to dehydration.
Preterm labor: Labor that starts before the 37th week of pregnancy.
Hyperemesis or hyperemesis gravidarum: Hyperemesis is severe and persistent nausea and vomiting during
pregnancy. Hyperemesis is more severe than ordinary morning sickness and leads to dehydration and other
nutritional problems. Some pregnant women with hyperemesis need to be hospitalized for IV fluid treatment.
Peeclampsia: Preeclampsia or toxemia is a condition marked by high blood pressure and by protein in the urine.
Preeclampsia usually develops in the second half of pregnancy and affects about 5% of pregnant women.
Appendix A
A.1.4.a–19
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
Rupture of membranes: Premature rupture of membranes occurs when the mother’s water, or amniotic fluid,
breaks before contractions start. It occurs in about 10% of normal pregnancies.
Kidney disorder: Women with a severe kidney disorder before pregnancy are more likely to have problems during
pregnancy. Kidney function may rapidly worsen during pregnancy. Acute kidney failure can also happen during a
pregnancy complication, such as preeclampsia.
TC8100. Did you receive any treatments? Please include any vaccinations you may have received.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC8300)
REFUSED .......................................................................................... 9--97 (TC8300)
DON’T KNOW .................................................................................... 9--98 (TC8300)
TC8200. What treatments did you receive?
INTERVIEWER INSTRUCTION:
ENTER ALL TREATMENTS IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC8300. If you haven’t yet, put a check mark in the box next to the visit that you just told me about in your Pregnancy
Medical Care Log. Have you had any other hospitalizations since {MONTH}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP TC04
LOOP:
IF TC8300 = “1”, CYCLE AGAIN.
OTHERWISE, CONTINUE WITH BOX TC06.
BOX TC05
CHECK ITEM:
IF 3 MONTH, GO TO TC8760.
IF 9 MONTH, CONTINUE WITH 8400.
Appendix A
A.1.4.b–1
Version 1/20/08
Visit Type: 6 Month
Target: Female
6-Month Visit: Introduction
IN0100. We are about to begin the interview portion of today’s home visit, which will take about 45 minutes to complete.
Your answers are important to us. There are no right or wrong answers, just those that help us to understand your
situation. There are questions about your child, where you live, your lifestyle routines, and your feelings during
this interview and you can always refuse to answer any question or group of questions. If you need a bathroom
break at any time please let me know so that I can give you the materials to collect the samples that are needed
today.
Before we start, can you get the medicines, any pesticide products, and the Infant Medical Care Log that you
were asked to gather for this appointment?
IN0200. AFTER RESPONDENT GATHERS MATERIALS, OR INDICATES THAT SHE DOESN’T HAVE ANY TO
GATHER, SAY:
Are you ready to begin?
YES ..........................................................................................................
NO ............................................................................................................
1
2 (END INTERVIEW)
Appendix A
A.1.4.b–2
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: Household Composition and Demographics: Part 1
DE0100. First, I’d like to update some information about the people who live here.
DE0200. How many people, both children and adults, live in this household? Include any persons who usually stay here but
are temporarily away on business, vacation, in the hospital, on full-time active military duty, or students living
temporarily away from home. Do not include anyone who is in a nursing home or other institution. Including
yourself, what is the total number of people who live here?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX DE01
CHECK ITEM:
IF DE0200 = “1,” GO TO DE0900.
OTHERWISE, CONTINUE WITH DE0300.
DE0300. Now I’d like to ask some questions about each person in your household, starting with the oldest. Please list
everyone who lives here, except yourself.
Version 1/20/08
Visit Type: 6 Month
Target: Mother
HH ENUMERATION GRID - QUESTIONS DE0400 – DE0800
DE0400. NAME: What is the (next) oldest person’s first name?
DE0500. AGE: How old is (NAME)?
DE0600. GENDER: Is (NAME) male or female?
DE0700. RELATIONSHIP TO RESPONDENT: Please refer to this card. What is (NAME’S) relationship to you?
DE0800. RELATIONSHIP TO STUDY CHILD: Please refer to this card. What is (NAME’S) relationship to (BABY NAME)?
PROBE: Now let me review the names that I have recorded. (READ NAMES FROM ROSTER.) Does this include all persons who usually stay here but are temporarily away
on business, vacation, in the hospital, on full time active military duty, or students living temporarily away from home?
INTERVIEWER INSTRUCTION:
NAME: COLLECT UNIQUE NAME.
AGE: ENTER “1” IF LESS THAN 1 YEAR.
GENDER: IF KNOWN, SELECT GENDER WITHOUT ASKING.
RELATIONSHIP TO RESPONDENT: SHOW CARD DE1.
RELATIONSHIP TO STUDY CHILD: SHOW CARD DE 2. IF ENUMERATING STUDY CHILD SELECT “SELF” WITHOUT ASKING.
MAKE SURE TO VERIFY ALL HOUSEHOLD MEMBERS HAVE BEEN ENTERED BEFORE MOVING ON TO THE NEXT SCREEN.
DE0600. RELATIONSHIP TO RESPONDENT
DE0500. AGE
DE0400. NAME
__________________
UNIQUE FIRST NAME
|___|___|___|
AGE
REFUSED ........................... 9--97
DON’T KNOW...................... 9--98
REFUSED ............................ 9--97
DON’T KNOW ...................... 9--98
Appendix A
SELF ............................................................ 00
SPOUSE ...................................................... 01
BIOLOGICAL SON/DAUGHTER.................. 02
ADOPTED SON/DAUGHTER ...................... 03
STEPSON/STEPDAUGHTER...................... 04
BROTHER/SISTER...................................... 05
FATHER/MOTHER ...................................... 06
GRANDCHILD.............................................. 07
PARENT-IN-LAW ......................................... 08
SON-IN-LAW/DAUGHTER-IN-LAW ............. 09
ROOMER, BOARDER.................................. 10
HOUSEMATE, ROOMMATE........................ 11
UNMARRIED PARTNER.............................. 12
FOSTER CHILD ........................................... 13
OTHER NONRELATIVE............................... 14
OTHER RELATIVE....................................... 15
REFUSED .............................................. 9--97
DON’T KNOW ........................................ 9--98
DE0800. RELATIONSHIP TO
STUDY CHILD
SELF ..................................... 0
BROTHER/SISTER ............... 1
FATHER/MOTHER................ 2
GRANDPARENT ................... 3
OTHER NONRELATIVE........ 4
OTHER RELATIVE................ 5
REFUSED ....................... 9--97
DON’T KNOW ................. 9--98
A.1.4.b–3
Appendix A
A.1.4.b–4
Version 1/20/08
Visit Type: 6 Month
Target: Mother
DE0900 Now I’d like to ask about your marital status. What is your current marital status? Are you:
INTERVIEWER INSTRUCTION:
CONFIRM IF KNOWN.
Married, .................................................................................................... 01
Not married but living together with a partner of the opposite sex,........... 02
Not married but living together with a partner of the same sex,................ 03
Widowed,.................................................................................................. 04
Divorced, .................................................................................................. 05
Separated, or............................................................................................ 06
Never been married?................................................................................ 07
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BEGIN LOOP DE01
LOOP:
ASK DE1000-DE1300 ABOUT RESPONDENT.
CYCLE THROUGH AND ASK DE1000–DE1300 ABOUT SPOUSE OR
RESIDENT PARTNER IF APPLICABLE (RECORD CODED “1” OR “12” IN
DE0700).
DE1000. {Do you/Does {NAME}} consider {yourself/himself/herself} to be Hispanic, or Latin{o/a}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DE1200)
REFUSED .......................................................................................... 9--97 (DE1200)
DON’T KNOW .................................................................................... 9--98 (DE1200)
DE1100. Please give me the number of the group that best represents {your/{NAME}’s} Hispanic origin or ancestry.
SHOW CARD DE3.
PUERTO RICAN ...................................................................................... 01
CUBAN/CUBAN AMERICAN ................................................................... 02
DOMINICAN (REPUBLIC)........................................................................ 03
MEXICAN ................................................................................................. 04
MEXICAN AMERICAN ............................................................................. 05
CENTRAL OR SOUTH AMERICAN ......................................................... 06
OTHER..................................................................................................... 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–5
Version 1/20/08
Visit Type: 6 Month
Target: Mother
DE1200. What race {do/does} {you/{NAME}} consider {yourself/(himself/herself)} to be?
PROBE: Anything else?
SELECT ALL THAT APPLY.
White, ....................................................................................................... 01
Black or African American, ....................................................................... 02
Asian, ....................................................................................................... 03
Native Hawaiian or Other Pacific Islander, ............................................... 04
American Indian or Alaska Native, or ....................................................... 05
Some other race (SPECIFY): __________________________________ 94
Some other race (SPECIFY): __________________________________ 95
Some other race (SPECIFY): __________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
DE1300 Please look at the card and tell me what is the highest degree or level of school that {you/{NAME}} {have/has}
completed?
SHOW CARD DE4.
NO SCHOOL............................................................................................ 01
NURSERY–4TH GRADE ........................................................................... 02
5TH–6TH GRADE ....................................................................................... 03
7TH–8TH GRADE ....................................................................................... 04
9TH GRADE .............................................................................................. 05
10TH GRADE ............................................................................................ 06
11TH GRADE ............................................................................................ 07
12TH GRADE ............................................................................................ 08
HIGH SCHOOL DIPLOMA ....................................................................... 09
GED ......................................................................................................... 10
< 1 YEAR COLLEGE................................................................................ 11
1+ YEARS COLLEGE, NO DEGREE....................................................... 12
ASSOCIATE: VOCATIONAL.................................................................... 13
ASSOCIATE: ACADEMIC ........................................................................ 14
BACHELOR’S DEGREE .......................................................................... 15
MASTER’S DEGREE ............................................................................... 16
PROFESSIONAL DEGREE .................................................................... 17
DOCTORAL DEGREE ............................................................................. 18
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP DE01
LOOP:
ASK DE1000–DE1300 ABOUT SPOUSE OR RESIDENT PARTNER IF
APPLICABLE (RECORD CODED “1” OR “12” IN DE0700).
WHEN COMPLETE, CONTINUE WITH NEXT SECTION.
IF NO SPOUSE OR RESIDENT PARTNER (NO RECORD CODED “1” OR “12”
IN DE0700, CONTINUE WITH NEXT SECTION.
Appendix A
A.1.4.b–6
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: Child Medical History
CM0100.Now I’ll ask you about your baby’s sleeping.
CM0200.Does your baby usually sleep in your bedroom or in a different room at night?
IN RESPONDENT’S ROOM..................................................................... 1
IN A DIFFERENT ROOM ......................................................................... 2
BOTH IN RESPONDENT’S ROOM AND A DIFFERENT ROOM............. 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM0300.What does your baby sleep in at night?
A bassinette,............................................................................................. 1
A crib, ....................................................................................................... 2
A co-sleeper, ............................................................................................ 3
In the bed or other place with you, or ....................................................... 4
In something else? (SPECIFY): ________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM0400.In what position do you most often lay the baby down to sleep at night? On their..
Side, ......................................................................................................... 1
Stomach, or .............................................................................................. 2
Back? ....................................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM0500.In what position do you most often lay the baby down for naps? On their…
Side, ......................................................................................................... 1
Stomach, or .............................................................................................. 2
Back? ....................................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM0600.Does your baby have a regular sleeping routine now?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–7
Version 1/20/08
Visit Type: 6 Month
Target: Mother
CM0700.Approximately how many hours does your baby sleep during the day?
|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CM0800.Approximately how many hours does your baby sleep at night?
|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CM0900.On a normal day, what time in the evening does your baby go to sleep?
|___|___|:|___|___|
TIME
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CM1000.On a normal day, what time does your baby wake up in the morning?
|___|___|:|___|___|
TIME
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CM1100.How often is your baby difficult when {he/she} is put to bed?
Most of the time,....................................................................................... 1
Often, ....................................................................................................... 2
Sometimes, .............................................................................................. 3
Rarely, or.................................................................................................. 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–8
Version 1/20/08
Visit Type: 6 Month
Target: Mother
CM1200.How often does your baby wake at night?
Never,....................................................................................................... 1
Occasionally, ............................................................................................ 2
Most nights, .............................................................................................. 3
Every night, or .......................................................................................... 4
More than once per night?........................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(CM1500)
(CM1400)
(CM1400)
(CM1400)
(CM1400)
(CM1400)
CM1300.How many times does your baby wake per night?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CM1400.Please look at the card and tell me, when your baby wakes up at night how often do you:
SHOW CARD CM1.
ALWAYS
a.
b.
c.
d.
e.
f.
Feed {him/her} milk? ................................
Give {him/her} another drink? ..................
Rock or cuddle {him/her}? ........................
Give {him/her} a pacifier?.........................
Bring {him/her} into your bed?..................
Change {his/her} diaper? .........................
1
1
1
1
1
1
USUALLY SOMETIMES
2
2
2
2
2
2
NEVER
RF
DK
4
4
4
4
4
4
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
3
3
3
3
3
3
CM1500.Now I’d like to change the subject and ask about your child’s health and development. You may notice your
baby’s personality developing a bit more now that he or she is 6 months old. Overall would you describe your
baby as:
YES
NO
RF
DK
a.
b.
c.
d.
e.
f.
g.
Calm?...................................................................................................
Worried? ..............................................................................................
Sociable or outgoing? ..........................................................................
Angry?..................................................................................................
Shy or quiet? ........................................................................................
Stubborn? ............................................................................................
Happy?.................................................................................................
1
1
1
1
1
1
1
CM1600.Since {CHILD} was born, would you say {CHILD’s} health has been poor, fair, good, excellent?
POOR....................................................................................................... 1
FAIR ......................................................................................................... 2
GOOD ...................................................................................................... 3
EXCELLENT ............................................................................................ 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
Appendix A
A.1.4.b–9
Version 1/20/08
Visit Type: 6 Month
Target: Mother
CM1700.I will read you a list of things your baby may already do or may start doing when {he/she} gets older. Does your
baby…
YES
NO
RF
DK
Follow you with {his/her} eyes? ................................................................
Smile when you smile at him/her?............................................................
Try to get a toy that is out of reach? .........................................................
Feed {him/herself} a cracker or cereal?....................................................
Wave goodbye? .......................................................................................
Reaches for toys or food held to him/her?................................................
Grab an object like a block or rattle from you? .........................................
Move a toy or block from one hand to the other? .....................................
Pick up a small object like a Cheerio or raisin? ........................................
Hold two toys or blocks at a time, one in each hand? ..............................
Startle or react to a sound? ......................................................................
Turns towards a sound? ...........................................................................
Turns toward someone when they’re speaking? ......................................
Makes sounds as though he/she is trying to speak? ................................
Says mama or dada? ...............................................................................
Can keep head steady when sitting or held up?.......................................
Rolls over from stomach to back? ............................................................
Rolls from back to stomach? ....................................................................
Sit up by {him/herself}? ............................................................................
Stand while holding onto something? .......................................................
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
CM1800.Has {CHILD} ever had a runny nose, cough, or cold?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CM2000)
REFUSED .......................................................................................... 9--97 (CM2000)
DON’T KNOW .................................................................................... 9--98 (CM2000)
CM1900.How old was {he/she} when {he/she} first had a runny nose, cough, or cold?
|___|___|
NUMBER
DAYS........................................................................................................
WEEKS ....................................................................................................
MONTHS..................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
9--97
9--98
CM2000.Has {CHILD} ever had an ear infection?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CM2200)
REFUSED .......................................................................................... 9--97 (CM2200)
DON’T KNOW .................................................................................... 9--98 (CM2200)
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
Appendix A
A.1.4.b–10
Version 1/20/08
Visit Type: 6 Month
Target: Mother
CM2100.How old was {he/she} when {he/she} first had an ear infection?
|___|___|
NUMBER
DAYS........................................................................................................
WEEKS ....................................................................................................
MONTHS..................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
9--97
9--98
CM2200.Has {CHILD} ever had diarrhea or vomiting?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CM2400)
REFUSED .......................................................................................... 9--97 (CM2400)
DON’T KNOW .................................................................................... 9--98 (CM2400)
CM2300.How old was {he/she} when {he/she} first had diarrhea or vomiting?
|___|___|
NUMBER
DAYS........................................................................................................
WEEKS ....................................................................................................
MONTHS..................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
9--97
9--98
CM2400.Has {CHILD} ever had wheezing or whistling in the chest?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CM2600)
REFUSED .......................................................................................... 9--97 (CM2600)
DON’T KNOW .................................................................................... 9--98 (CM2600)
CM2500.How old was {he/she} when {he/she} first had wheezing or whistling in the chest?
|___|___|
NUMBER
DAYS........................................................................................................
WEEKS ....................................................................................................
MONTHS..................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
1
2
3
9--97
9--98
Appendix A
A.1.4.b–11
Version 1/20/08
Visit Type: 6 Month
Target: Mother
CM2600.Since {CHILD} was born, on how many days has {CHILD} had a fever over 101 degrees, not related to receiving
immunizations? (IF NEEDED: or 38.3 degrees Celsius?)
|___|___|___|
NUMBER OF DAYS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CM2700.Now I have some questions about specific conditions or health problems {CHILD} may have.
CM2800.Has a doctor ever told you that {CHILD} is blind?
YES .......................................................................................................... 1 (CM3000)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM2900.Has a doctor ever told you that {CHILD} has difficulty seeing, including nearsightedness and farsightedness?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM3000.Has a doctor ever told you that {CHILD} has difficulty hearing or deafness? Do not include a temporary loss of
hearing due to a cold or congestion.
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM3100.Has a doctor ever told you that {CHILD} has any congenital anomaly or birth defect such as a cleft lip or palate,
heart defect, or spina bifida?
YES (SPECIFY) ____________________________________________ 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM3200.Has a doctor ever told you that {CHILD} has failure to thrive, or concern about proper growth?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–12
Version 1/20/08
Visit Type: 6 Month
Target: Mother
CM3300.Has a doctor ever told you that {CHILD} has a problem with using {his/her} arms or hands?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM3400.Has a doctor ever told you that {CHILD} has Down Syndrome, Turner Syndrome, or other inherited or genetic
condition?
YES (SPECIFY): ___________________________________________ 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM3500.Has a doctor ever told you that {CHILD} has any other types of special needs or limitations?
YES (SPECIFY): ___________________________________________ 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX CM01
CHECK ITEM:
IF ANY CM2800-CM3500 = “1” AT CURRENT OR ANY PREVIOUS INTERVIEW,
CONTINUE WITH CM3600.
OTHERWISE GO TO CM3900.
CM3600.Next, I’m going to read a list of services. For each service, please tell me if {CHILD} or your family received this
service to help with {CHILD}’s special needs.
YES
NO
RF
DK
a.
b.
c.
d.
e.
f.
g.
Physical therapy?.................................................................................
Vision services? ...................................................................................
Hearing services? ................................................................................
Social work services?...........................................................................
Psychological services? .......................................................................
Home visits? ........................................................................................
Parent support or training?...................................................................
1
1
1
1
1
1
1
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
Appendix A
A.1.4.b–13
Version 1/20/08
Visit Type: 6 Month
Target: Mother
CM3700.Is {CHILD} currently participating in an early intervention program or regularly receiving any services for {his/her}
condition{s} from:
YES
NO
RF
DK
a.
b.
c.
d.
e.
f.
Your local school district? ....................................................................
A state or local health agency? ............................................................
A social service agency?......................................................................
A private doctor’s office?......................................................................
A clinic?................................................................................................
Some other source?.............................................................................
1
1
1
1
1
1
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
ROUTING INSTRUCTION: IF CM3700f = “1” CONTINUE. OTHERWISE, GO TO CM3900.
CM3800.What is that other source?
_______________________________
OTHER SOURCE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CM3900.The next questions are about the health insurance plans for {CHILD}. For this kind of insurance, people often pay
part of the premium and they may obtain it through work, purchase it directly, or receive it through a state or local
government program or community program.
CM4000.Is {CHILD} covered by any kind of health insurance or some other kind of health care plan?
PROBE: Include health insurance obtained through employment or purchased directly, as well as government
programs like Medicaid and CHIP that provide medical care or help pay bills?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
CM4100 What kind of health insurance or health care coverage does {CHILD} have? Does {he/she} have coverage
through a private health insurance plan (from employer, workplace, or purchased directly, or through a state or
local government program or community program)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–14
Version 1/20/08
Visit Type: 6 Month
Target: Mother
CM4200.(Does {he/she} have coverage through)
Medicaid {or name of state program}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM4300.(Does {he/she} have coverage through)
CHIP (Children’s Health Insurance Program) {or name of state program}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM4400.(Does {he/she} have coverage through)
Military health care/TRICARE/CHAMPUS/CHAMP-VA?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM4500.(Does {he/she} have coverage through)
Indian Health Service?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM4600.(Does {he/she} have coverage through)
Another government program (Medicare {, {State-sponsored health plan}})?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–15
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: Health Behaviors
HB0100. The following questions are about your sleep habits during the past 7 days.
HB0200. Thinking of the past 7 days, on a typical day, how much time did you sleep at night?
Less than 4 hours,.................................................................................... 1
4–5 hours, ................................................................................................ 2
6–7 hours, ................................................................................................ 3
8–9 hours, or ............................................................................................ 4
10 or more hours? .................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB0300. During the past 7 days, on a typical day, how much additional time did you sleep during the day?
Not at all, .................................................................................................. 1
Less than 1 hour,...................................................................................... 2
1–2 hours, or ............................................................................................ 3
More than 2 hours? .................................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB0400. The next questions are about your child’s exposure to environmental tobacco smoke.
HB0500. Do you currently smoke cigarettes or use any other tobacco product?
YES ......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB0600. {Including yourself, how/How} many smokers live in your home now?
|___|___|
NUMBER OF SMOKERS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
HB0700. {Do you/Does anyone} smoke inside the house?
YES ......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–16
Version 1/20/08
Visit Type: 6 Month
Target: Mother
HB0800. Which of the following statements describes the rules about smoking inside your home now?
No one is allowed to smoke anywhere inside my home, .......................... 1
Smoking is allowed in some rooms at some times, or.............................. 2
Smoking is permitted anywhere inside my home ..................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB0900.On average, about how many hours per day do people smoke in the same room as {CHILD}, or near enough
that {he/she} can see or smell the smoke? Please consider all the places {CHILD} is during the day, including at
home, at daycare, or some other place. If {he/she} is not exposed to smoke, enter “0.”
|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
HB1000.Do you drink any type of alcoholic beverage?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
HB1100. How often do you have 5 or more drinks within a couple of hours:
Never,....................................................................................................... 1
About once a month, ................................................................................ 2
About once a week, or.............................................................................. 3
About once a day? ................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–17
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: Parenting Practices and Beliefs
PB0100. These next questions are about different things you may do as a parent. How often do you feel the following ways
or do the following things?
PB0200. How often do you talk a lot about your child to friends and family?
SHOW CARD PB1.
All of the time,........................................................................................... 1
Some of the time, ..................................................................................... 2
Rarely, or ................................................................................................. 3
Never?...................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB0300. How often do you carry pictures of your child with you wherever you go?
SHOW CARD PB1.
ALL OF THE TIME ................................................................................... 1
SOME OF THE TIME ............................................................................... 2
RARELY ................................................................................................... 3
NEVER ..................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB0400. How often do you find yourself thinking about your child?
SHOW CARD PB1.
ALL OF THE TIME ................................................................................... 1
SOME OF THE TIME ............................................................................... 2
RARELY ................................................................................................... 3
NEVER ..................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB0500. How often do you think holding and cuddling your child is fun?
SHOW CARD PB1.
ALL OF THE TIME ................................................................................... 1
SOME OF THE TIME ............................................................................... 2
RARELY ................................................................................................... 3
NEVER ..................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–18
Version 1/20/08
Visit Type: 6 Month
Target: Mother
PB0600. How often do you think it’s more fun to get your child something new than to get yourself something new?
SHOW CARD PB1.
ALL OF THE TIME ................................................................................... 1
SOME OF THE TIME ............................................................................... 2
RARELY ................................................................................................... 3
NEVER ..................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB0700. How strongly do you agree or disagree with the following statement. Babies have to learn they can’t be picked up
every time they cry.
Strongly agree, ......................................................................................... 1
Agree,....................................................................................................... 2
Neither agree nor disagree,...................................................................... 3
Disagree, or.............................................................................................. 4
Strongly disagree? ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB0800. Do you read to or look at books with your child?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PB1000)
REFUSED .......................................................................................... 9--97 (PB1000)
DON’T KNOW .................................................................................... 9--98 (PB1000)
PB0900. How often do you read or look at books with your child?
Every day, ................................................................................................ 1
5–6 days a week, ..................................................................................... 2
2–4 days a week, or ................................................................................. 3
Once a week or less? ............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1100. Does your child watch TV and/or DVDs?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PB1800)
REFUSED .......................................................................................... 9--97 (PB1800)
DON’T KNOW .................................................................................... 9--98 (PB1800)
Appendix A
A.1.4.b–19
Version 1/20/08
Visit Type: 6 Month
Target: Mother
PB1200. How often does your child watch TV and/or DVDs?
Every day, ................................................................................................ 1
5–6 days a week, ..................................................................................... 2
2–4 days a week, or ................................................................................. 3
Once a week or less? ............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1800. How often do you play with toys with your baby?
Every day, ................................................................................................ 1
5–6 days a week, ..................................................................................... 2
2–4 days a week, or ................................................................................. 3
Once a week or less? ............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1600. How often do you go for walks with your baby?
Every day, ................................................................................................ 1
5–6 days a week, ..................................................................................... 2
2–4 days a week, or ................................................................................. 3
Once a week or less? ............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1700. This next few questions asks about how you think most young children act, how they grow, and how to care for
them.
Please answer each of the following questions based on young children in general, not about your child and how
he or she acts. Think about what you know about young children you have had contact with or anything you have
read.
For each of the following statements, say whether, for most young children, you agree or disagree with the
statement, or are not sure.
PB1800. All infants need the same amount of sleep.
SHOW CARD PB2.
AGREE..................................................................................................... 1
DISAGREE............................................................................................... 2
NOT SURE............................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–20
Version 1/20/08
Visit Type: 6 Month
Target: Mother
PB1900. A young brother or sister may start wetting the bed or thumbsucking when a new baby arrives in the family.
SHOW CARD PB2.
AGREE..................................................................................................... 1
DISAGREE............................................................................................... 2
NOT SURE............................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–21
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: Child Care Arrangements
Next, I’d like to ask you about different types of child care {CHILD} may receive from someone other than parents or
guardians. This includes regularly scheduled care arrangements with relatives and non-relatives, and day care or early
childhood programs, whether or not there is a charge or fee, but not occasional babysitting.
Section A: Any Regularly Scheduled Non-Parental Child Care
A01.
Does {CHILD} currently receive any regularly scheduled care from someone other than a parent or guardian, for
example from relatives, non-relatives, or a child care center or program?
Yes ........................................................................................................... 1
No............................................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX A02
CHECK ITEM:
IF CHILD IS CURRENTLY RECEIVING REGULAR NON-PARENTAL CARE (A01
= 1), GO TO SECTION B.
ELSE, END CHILD CARE ARRANGEMENTS SECTION.
Section B. Care by a Relative Other Than a Parent or Guardian
B01.
I’d like you to think about all the care {CHILD} receives from relatives, for example, from grandparents, brothers or
sisters, or any other relatives. This includes all regularly scheduled care arrangements with relatives that happen
at least weekly, but does not include occasional babysitting. Including all of these regular arrangements, how
many total hours each week does {CHILD} receive care from relatives?
|___|___|
NUMBER OF HOURS PER WEEK
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX B02
CHECK ITEM:
IF CHILD IS CURRENTLY RECEIVING CARE FROM RELATIVES FOR 10 OR
MORE HOURS PER WEEK (B01 > 10) GO TO B04.
ELSE, GO TO SECTION C.
Appendix A
A.1.4.b–22
Version 1/20/08
B04.
Visit Type: 6 Month
Target: Mother
How many care arrangements with relatives does {CHILD} have that are regularly scheduled for 10 hours or more
each week?
|___|___|
NUMBER OF CARE ARRANGEMENTS AT 10 HOURS OR MORE
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX B05
CHECK ITEM:
IF CHILD HAS ONE OR MORE RELATIVE CARE ARRANGEMENTS THAT
LAST FOR 10 OR MORE HOURS PER WEEK (B04 > 1), GO TO BOX B06.
ELSE, GO TO SECTION C.
BOX B06
CHECK ITEM:
ASK B07 THROUGH B31 FOR EACH RELATIVE WHO PROVIDES 10 OR
MORE HOURS PER WEEK OF CARE FOR CHILD
B07.
[Let’s start with the relative who provides the most care for {CHILD} now./Now let’s talk about the next relative
who cares for {CHILD}]. How is this person related to {CHILD}?
Grandmother ............................................................................................ 1
Grandfather .............................................................................................. 2
Aunt .......................................................................................................... 3
Uncle ........................................................................................................ 4
Brother...................................................................................................... 5
Sister ........................................................................................................ 6
Another Relative (SPECIFY): __________________________________ 7
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
B10.
Is the care provided by {{CHILD}’s {RELATIVE}/that relative} in your home or in another home?
Own home ................................................................................................ 1
Other home .............................................................................................. 2
Both/Varies............................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–23
Version 1/20/08
B13.
Visit Type: 6 Month
Target: Mother
Does {{CHILD}’s {RELATIVE}/that relative} who provides this care live in your household? PROBE: Include
persons living in in-law suites, above garages, or in quarters attached to house.
Yes ........................................................................................................... 1
No............................................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
B16.
How many hours each week does {CHILD} receive care from {{his/her}{RELATIVE}/that relative}?
|___|___|
NUMBER OF HOURS PER WEEK
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
B19.
9--97
9--98
How old was {CHILD} in months when this particular regular care arrangement with {{his/her} {RELATIVE}/that
relative} began?
|___|___|
AGE IN MONTHS WHEN CARE WITH RELATIVE BEGAN
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
B22.
9--97
9--98
How many children are usually cared for together, in the same group at the same time, by {{CHILD}’s
{RELATIVE}/that relative}, counting {CHILD}?
|___|___|
NUMBER OF CHILDREN
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
B25.
9--97
9--98
How many adults usually care for {CHILD} at the same time during that care arrangement?
|___|___|
NUMBER OF ADULTS
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.b–24
Version 1/20/08
B28.
Visit Type: 6 Month
Target: Mother
Does the child care provider allow you or other parents to leave children who are sick?
No, the parent/s have to make other arrangements if the child
is at all sick (e.g., a cold or sniffles but no fever, or fever under
some predetermined level, such as 100)............................................... 1
No, the parent/s have to make other arrangements if the child is
very sick (e.g., any fever over some predetermined level, such
as 100.1) ............................................................................................... 2
Yes, the parent/s can leave the child as usual ......................................... 3
Yes, the provider takes the child, but keeps him/her isolated from
other children (or there are no other children) ....................................... 4
Yes, the provider takes the child, and makes other arrangements
for the child (has someone else take care of the child, etc.).................. 5
Other (SPECIFY):___________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX B29
CHECK ITEM:
IF B10 = 2 or B10 = 3, GO TO B31.
ELSE, GO TO B37.
B31.
May I have the address where this relative provides care for your child? [IF NEEDED: We will not use this
information to contact your relative. We will only use this information for analysis.]
_____________________________________________________
STREET NUMBER
STREET NAME
APT #
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
BOX B29
CHECK ITEM:
IF (CITY AND STATE) OR ZIP WAS PROVIDED IN B31, GO TO BOX B35.
ELSE, GO TO B34.
B34.
About how many miles is the {CHILD}’s {RELATIVE/relative caregiver} from your house?
|___|___|
NUMBER OF MILES
Appendix A
A.1.4.b–25
Version 1/20/08
Visit Type: 6 Month
Target: Mother
BOX B35
CHECK ITEM:
IF B04 = 1 (ONE RELATIVE ARRANGEMENT), GO TO B37.
IF B04 > 2 (MORE THAN ONE RELATIVE ARRANGEMENT), RETURN TO B07
UNTIL THE NUMBER OF ARRANGEMENTS IN B04 IS COMPLETED, THEN GO
TO B37.
B37.
Does {CHILD} have another care arrangement with a relative that is regularly scheduled for 10 hours or more per
week?
Yes ........................................................................................................... 1 (GO TO B07)
No............................................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Section C: Care by a Non-Relative
Now I’d like to ask you about any regularly scheduled care {CHILD} receives from someone not related to {him/her}, either
in your home or someone else’s home. This includes all regularly scheduled care arrangements with non-relatives that
happen at least weekly, including home child care providers, regularly scheduled sitter arrangements, or neighbors. This
does not include day care centers, early childhood programs, or occasional babysitting.
C01.
I’d like you to think about all the regularly scheduled care your child receives on a weekly basis from non-relatives
in a home setting. Including all of these arrangements, how many total hours each week does {CHILD} receive
care from non-relatives in a home setting?
|___|___|
NUMBER OF HOURS PER WEEK
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX C02
CHECK ITEM:
IF CHILD IS CURRENTLY RECEIVING CARE FROM NON-RELATIVES FOR 10
OR MORE HOURS PER WEEK (C01 > 10), GO TO C04.
ELSE, GO TO SECTION D.
Appendix A
A.1.4.b–26
Version 1/20/08
C04.
Visit Type: 6 Month
Target: Mother
How many care arrangements with non-relatives does {CHILD} have that are regularly scheduled for 10 hours or
more each week?
|___|___|
NUMBER OF CARE ARRANGEMENTS AT 10 HOURS OR MORE
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX C05
CHECK ITEM:
IF CHILD HAS ONE OR MORE NON-RELATIVE CARE ARRANGEMENTS THAT
LAST FOR 10 OR MORE HOURS PER WEEK (C04 > 1), GO TO BOX C06.
ELSE, GO TO SECTION D.
BOX C06
CHECK ITEM:
ASK C07 THROUGH C28 FOR EACH NON-RELATIVE WHO PROVIDES 10 OR
MORE HOURS PER WEEK OF CARE FOR CHILD
C07.
[Let’s talk about the non-relative who provides the most care for {CHILD} now./Now let’s talk about the next nonrelative who cares for {CHILD}.]
Is that care provided in your home or another home?
Own home ................................................................................................ 1
Other home .............................................................................................. 2
Both/Varies............................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
C10.
Does this person who cares for {CHILD} live in your household? PROBE: Include persons living in in-law suites,
above garages, or in quarters attached to house.
Yes ........................................................................................................... 1
No............................................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–27
Version 1/20/08
C13.
Visit Type: 6 Month
Target: Mother
How many hours each week does {CHILD} receive care from that person?
|___|___|
NUMBER OF HOURS PER WEEK
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
C16.
9--97
9--98
How old was {CHILD} in months when this particular care arrangement began?
|___|___|
AGE IN MONTHS WHEN CARE BEGAN
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
C19.
9--97
9--98
How many children are usually cared for together, in the same group at the same time, by that person, counting
{CHILD}?
|___|___|
NUMBER OF CHILDREN
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
C22.
9--97
9--98
How many adults usually care for {CHILD} at the same time during that care arrangement?
|___|___|
NUMBER OF ADULTS
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.b–28
Version 1/20/08
C25.
Visit Type: 6 Month
Target: Mother
Does the child care provider allow you or other parents to leave children who are sick?
No, the parent/s have to make other arrangements if the child
is at all sick (e.g., a cold or sniffles but no fever, or fever under
some predetermined level, such as 100)............................................... 1
No, the parent/s have to make other arrangements if the child is
very sick (e.g., any fever over some predetermined level, such
as 100.1) ............................................................................................... 2
Yes, the parent/s can leave the child as usual ......................................... 3
Yes, the provider takes the child, but keeps him/her isolated from
other children (or there are no other children) ....................................... 4
Yes, the provider takes the child, and makes other arrangements
for the child (has someone else take care of the child, etc.).................. 5
Other (SPECIFY):___________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX C23
CHECK ITEM:
IF C07 = 2 or C07 = 3, GO TO C28.
ELSE, GO TO C34.
C28.
May I have the address where this person provides care for your child? [IF NEEDED: We will not use this
information to contact your child’s care provider. We will only use this information for analysis.]
_____________________________________________________
STREET NUMBER
STREET NAME
APT #
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
BOX C29
CHECK ITEM:
IF (CITY AND STATE) OR ZIP WAS PROVIDED IN C28, GO TO BOX C32.
ELSE, GO TO C31.
C31.
About how many miles is the {CHILD}’s {RELATIVE/relative caregiver} from your house?
|___|___|
NUMBER OF MILES
Appendix A
A.1.4.b–29
Version 1/20/08
Visit Type: 6 Month
Target: Mother
BOX C32
CHECK ITEM:
IF C04 = 1 (ONE NON-RELATIVE ARRANGEMENT), GO TO C34.
IF C04 > 2 (MORE THAN ONE 10 HOUR NON-RELATIVE ARRANGEMENT),
RETURN TO C07 UNTIL THE NUMBER OF ARRANGEMENTS IN C04 IS
COMPLETED, THEN GO TO C34.
C34.
Does {CHILD} have another care arrangement with a non-relative that is regularly scheduled for 10 hours or more
each week?
Yes ........................................................................................................... 1 (GO TO C07)
No............................................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Section D. Center-Based Care
Now I want to ask you about child care centers {CHILD} may attend on a regular basis. Such centers include day care
centers, early learning centers, nursery schools, and preschools.
D01.
I’d like you to think about all the care your child receives from child care centers. This includes all regularly
scheduled care arrangements in child care centers that happen at least weekly. Including all of these
arrangements, how many total hours each week does {CHILD} receive care at child care centers?
|___|___|
NUMBER OF HOURS PER WEEK
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX D02
CHECK ITEM:
IF CHILD IS CURRENTLY RECEIVING CENTER-BASED CARE FOR 10 OR
MORE HOURS PER WEEK, GO TO D04.
ELSE, END CHILD CARE INTERVIEW.
D04.
How many different child care center arrangements does {CHILD} have, where {CHILD} goes for at least 10 hours
each week?
|___|___|
NUMBER OF CARE ARRANGEMENTS AT 10 HOURS OR MORE
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.b–30
Version 1/20/08
Visit Type: 6 Month
Target: Mother
BOX D05
CHECK ITEM:
IF CHILD HAS ONE OR MORE CENTER-BASED CARE ARRANGEMENT THAT
LASTS FOR 10 OR MORE HOURS PER WEEK (D04 > 1), GO TO BOX D06.
ELSE, END CHILD CARE INTERVIEW.
BOX D06
CHECK ITEM:
ASK D07 THROUGH D22 FOR EACH CHILD CARE CENTER WHERE THE
CHILD SPENDS 10 OR MORE HOURS PER WEEK.
D07.
[Let’s talk about the program where {CHILD} spends most of his/her time./Now let’s talk about the next program
that {CHILD} currently goes to.] How many hours each week does {CHILD} go to that program?
|___|___|
NUMBER OF HOURS PER WEEK
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
D10.
9--97
9--98
How old was {CHILD} in months when {he/she} started going to this particular program?
|___|___|
AGE IN MONTHS WHEN CARE BEGAN
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
D13.
9--97
9--98
How many children are usually in {CHILD}’s room or group, at the same time, at that program, counting {CHILD}?
|___|___|
NUMBER OF CHILDREN
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.b–31
Version 1/20/08
D16.
Visit Type: 6 Month
Target: Mother
How many adults are usually in {CHILD}’s room or group, at the same time, at that program?
|___|___|
NUMBER OF ADULTS
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
D19.
9--97
9--98
Does the child care provider allow you or other parents to leave children who are sick?
No, the parent/s have to make other arrangements if the child
is at all sick (e.g., a cold or sniffles but no fever, or fever under
some predetermined level, such as 100)............................................... 1
No, the parent/s have to make other arrangements if the child is
very sick (e.g., any fever over some predetermined level, such
as 100.1) ............................................................................................... 2
Yes, the parent/s can leave the child as usual ......................................... 3
Yes, the provider takes the child, but keeps him/her isolated from
other children (or there are no other children) ....................................... 4
Yes, the provider takes the child, and makes other arrangements
for the child (has someone else take care of the child, etc.).................. 5
Other (SPECIFY):___________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
D22.
May I have the address of this child care program? [IF NEEDED: We will not use this information to contact your
child’s care provider. We will only use this information for analysis.]
_____________________________________________________
STREET NUMBER
STREET NAME
APT #
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
BOX D23
CHECK ITEM:
IF (CITY AND STATE) OR ZIP WAS PROVIDED IN D22, GO TO BOX D26.
ELSE, GO TO D25.
D25.
About how many miles is the {CHILD}’s {RELATIVE/relative caregiver} from your house?
|___|___|
NUMBER OF MILES
Appendix A
A.1.4.b–32
Version 1/20/08
Visit Type: 6 Month
Target: Mother
BOX D26
CHECK ITEM:
IF D04 = 1 (ONE 10 HOUR CENTER-BASED ARRANGEMENT), GO TO D28.
IF D04 > 2 (MORE THAN ONE 10 HOUR CENTER-BASED ARRANGEMENT),
RETURN TO D07 UNTIL THE NUMBER OF ARRANGEMENTS IN D04 IS
COMPLETED, THEN GO TO D28.
D28.
Does {CHILD} go to another child care center for at least 10 hours a week?
Yes ........................................................................................................... 1 (GO TO D07)
No............................................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–33
Version 1/20/08
Visit Type: 6 Month
Target: Female
6-Month Visit: Doctor Visits and Hospitalizations
CV0100. I am now going to ask some questions about your child’s visits to a doctor or other health care provider. Please
include routine well visits, sick visits, and any other visits to a doctor or other health care provider at a clinic,
doctor’s office or HMO, emergency room, or hospital outpatient department. Please refer to the Infant Medical
Care Log that you received as part of this study or to any other personal record or calendar that you keep that
would help you to remember the dates of these visits. I’ll be asking you to put a checkmark in the box next to each
visit once you’ve finished telling me about it. If you have this information available, please go and get it now.
CV0200.Since {MONTH} has {CHILD} seen a doctor or heath care provider for any reason?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
BEGIN LOOP CV01
LOOP:
CYCLE THROUGH CV0300–CV1600 FOR EACH VISIT TO A DOCTOR OR
OTHER HEALTH CARE PROVIDER.
CV0300. {Beginning with the most recent visit, please give me the date of the visit/Please give me the date of the next most
recent visit.}
INTERVIEWER INSTRUCTION:
ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR.
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV0400. What kind of place did you take your child to—a clinic or health center, doctor’s office or HMO, a hospital
emergency room, a hospital outpatient department, or some other place?
CLINIC OR HEALTH CENTER ................................................................ 1
DOCTOR’S OFFICE OR HMO................................................................. 2
HOSPITAL EMERGENCY ROOM ........................................................... 3
HOSPITAL OUTPATIENT DEPARTMENT .............................................. 4
SOME OTHER PLACE (SPECIFY):_____________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–34
Version 1/20/08
Visit Type: 6 Month
Target: Female
CV0500. What was the main reason for the visit?
Routine well visit,...................................................................................... 1
Sick visit, or ............................................................................................. 3
Some other reason? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(CV1400)
(CV1400)
(CV1400)
(CV1400)
CV0600. At this visit, what was your child’s weight?
WEIGHT MEASURED..............................................................................
WEIGHT NOT MEASURED .....................................................................
1
2 (CV0800)
CV0700. (At this visit, what was your child’s weight?)
|___|___|
POUNDS
OR
|___|___|.|__|
KILOGRAMS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV0800. At this visit, what was your child’s length?
LENGTH/HEIGHT MEASURED ...............................................................
LENGTH/HEIGHT NOT MEASURED ......................................................
1
2 (CV1000)
CV0900. (At this visit, what was your child’s length?)
|___|___|.|__|
INCHES
OR
|___|___|.|__|
CENTIMETERS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.b–35
Version 1/20/08
Visit Type: 6 Month
Target: Female
CV1000. At this visit, what was your child’s head circumference?
HEAD CIRCUMFERENCE MEASURED..................................................
HEAD CIRCUMFERENCE NOT MEASURED .........................................
1
2 (CV1200)
CV1100. (At this visit, what was your child’s head circumference?)
|___|___|.|__|
INCHES
OR
|___|___|.|__|
CENTIMETERS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV1200. Did your child receive any vaccinations at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CV1600)
REFUSED .......................................................................................... 9--97 (CV1600)
DON’T KNOW .................................................................................... 9--98 (CV1600)
CV1300. What did {he/she} receive? What was the lot number for the vaccine your child received?
RECEIVED
YES
NO
Hepatitis B ................................................................................................
Diphtheria, Tetanus, and Pertussis (DTaP) ..............................................
H. Influenza Type B (Hib) .........................................................................
Inactivated Polio (IPV) ..............................................................................
Pneumococcal Conjugate (PCV7)............................................................
Measles, Mumps, and Rubella (German measles)...................................
Varicella (Chickenpox) .............................................................................
Hepatitis A ................................................................................................
Influenza...................................................................................................
Rotavirus ..................................................................................................
Meningococcal .........................................................................................
Other (SPECIFY):___________________________________________
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
CV1400. Did a doctor or other health care provider give your child a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CV1600)
REFUSED .......................................................................................... 9--97 (CV1600)
DON’T KNOW .................................................................................... 9--98 (CV1600)
LOT NUMBER
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Appendix A
A.1.4.b–36
Version 1/20/08
Visit Type: 6 Month
Target: Female
CV1500. What was the diagnosis?
INTERVIEWER INSTRUCTION:
ENTER ALL DIAGNOSES IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
DIAGNOSES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV1600. Did your child receive any treatments at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CV1800)
REFUSED .......................................................................................... 9--97 (CV1800)
DON’T KNOW .................................................................................... 9--98 (CV1800)
CV1700. What treatments did {he/she} receive?
INTERVIEWER INSTRUCTION:
ENTER ALL TREATMENTS IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV1800 If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Infant Medical
Care Log. Has your child had any other visits to a doctor or other health care provider since {MONTH}? Please
include routine well visits, as well as visits to a doctor or other health care provider either at a clinic, doctor’s office
or HMO, emergency room, or outpatient department for any other reason.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_CV01)
REFUSED .......................................................................................... 9--97 (EL_CV01)
DON’T KNOW .................................................................................... 9--98 (EL_CV01)
END LOOP CV01
LOOP:
IF CV1800 = “1,” CYCLE AGAIN.
OTHERWISE, END LOOP AND CONTINUE WITH CV1900.
Appendix A
A.1.4.b–37
Version 1/20/08
Visit Type: 6 Month
Target: Female
CV1900. Since {MONTH} has your child spent at least one night in the hospital?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX CV04)
REFUSED .......................................................................................... 9--97 (BOX CV04)
DON’T KNOW .................................................................................... 9--98 (BOX CV04)
BEGIN LOOP CV02
LOOP:
CYCLE THROUGH CV2000–CV2600 FOR EACH HOSPITALIZATION.
CV2000. What was the admission date of your child’s {next} most recent hospitalization?
INTERVIEWER INSTRUCTION:
ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR.
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV2100. How many nights did your child stay at the hospital during this hospitalization?
|___|___|___|
NUMBER OF NIGHTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV2200. Did a doctor or other health care provider give your child a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CV2400)
REFUSED .......................................................................................... 9--97 (CV2400)
DON’T KNOW .................................................................................... 9--98 (CV2400)
CV2300. What was the diagnosis?
INTERVIEWER INSTRUCTION:
ENTER ALL DIAGNOSES IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
DIAGNOSES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.b–38
Version 1/20/08
Visit Type: 6 Month
Target: Female
CV2400. Did your child receive any treatments? Please include any vaccinations your child may have received.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CV2600)
REFUSED .......................................................................................... 9--97 (CV2600)
DON’T KNOW .................................................................................... 9--98 (CV2600)
CV2500. What treatments did your child receive?
INTERVIEWER INSTRUCTION:
ENTER ALL TREATMENTS IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV2600. If you haven’t yet, put a check mark in the box next to the visit that you just told me about in your Infant Medical
Care Log. Has your child had any other hospitalizations since {MONTH}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP CV02
LOOP:
IF CV2600 = “1,” CYCLE AGAIN.
OTHERWISE, CONTINUE WITH NEXT SECTION.
Appendix A
A.1.4.b–39
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: Use of Medicines, Supplements, and Alternative Medicines
UM0100.The next questions are about the prescription medications, over-the-counter medications, and dietary
supplements that you have given to your child since {he/she} was born. Do not include medications or
supplements {he/she} may have received while {he/she} was still in the hospital.
UM0200.Since your child was born, have you given {him/her} a medication for which a prescription is needed? Include only
those products prescribed by a health professional such as a doctor or dentist. Please include prescription
vitamins or minerals.
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM0300.Since your child was born, have you given {him/her} any over-the-counter or nonprescription medications, or any
nonprescription vitamins, minerals, herbals, or other dietary supplements? This card lists some examples of
different types of over-the-counter medications, vitamins, minerals, and dietary supplements.
SHOW CARD UM1.
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX UM01
CHECK ITEM:
IF UM0200 OR UM0300 = “1,” CONTINUE WITH UM0400.
OTHERWISE, GO TO EOS.
UM0400.May I please see the containers for all the {prescriptions,} {and} {non-prescription medicines and supplements},
that you gave to your child since {he/she} was born?
RESPONDENT HAS CONTAINERS........................................................
RESPONDENT DOES NOT HAVE CONTAINERS..................................
BOX UM02
CHECK ITEM:
IF UM0200 = “1,” CONTINUE WITH UM0500.
OTHERWISE, GO TO BOX UM03.
1
2
Appendix A
A.1.4.b–40
Version 1/20/08
Visit Type: 6 Month
Target: Mother
UM0500.I will start with the prescription medications. {Please show me any prescription medications and supplements you
have given your child since {he/she} was born./Please tell me the names of the prescription medications and
supplements that you have given your child since {he/she} was born.} Prescription medications and supplements
may include products like antibiotics for ear infections, or iron supplements prescribed by a doctor.
PROBE: Have you given your child any other prescription medications since {he/she} was born that we missed?
Please include prescriptions {he/she} may not be currently taking, but has finished since {he/she} was born.
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER.
ACTIVATE LOOKUP AND SELECT MEDICATIONS FROM LIST. CHECK TO MAKE SURE THAT BOTH THE
BRAND AND TYPE OR FORMULA MATCH. IF A MEDICATION IS NOT ON LIST, ENTER THE FULL NAME
(INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
CONFIRM ALL MEDICATIONS ENTERED BEFORE MOVING TO NEXT SCREEN.
PRODUCT ON PRESCRIPTION MEDICINE LIST .................................. 1
PRODUCT NOT ON LIST (SPECIFY): __________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BEGIN LOOP UM01
LOOP:
CYCLE THROUGH UM0600–UM1000 FOR EACH PRESCRIPTION.
UM0600.{First/Next}, let’s talk about {MEDICATION}.
UM0700.PRODUCT LABEL SEEN?
YES ..........................................................................................................
NO ............................................................................................................
1
2
UM0800.RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK:
How is the {MEDICATION} taken:
By mouth, ................................................................................................ 01
Inhaled either by mouth or nose, .............................................................. 02
Injected,.................................................................................................... 03
Applied to the skin, such as a patch or creams, or ................................... 04
Some other way? (SPECIFY): _________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM0900.When did you start giving your child {MEDICATION}:
Within the last month, ............................................................................... 1
1–3 months ago, or .................................................................................. 2
More than 3 months ago?......................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–41
Version 1/20/08
Visit Type: 6 Month
Target: Mother
UM1000.Are you still giving {CHILD} {MEDICATION}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP UM01
LOOP:
CYCLE THROUGH UM0600–UM1000 FOR THE NEXT PRESCRIPTION
MEDICATION IN ROSTER.
WHEN FINISHED WITH ALL MEDICATIONS LISTED IN ROSTER CONTINUE
WITH BOX UM03.
BOX UM03
CHECK ITEM:
IF UM0300 = “1,” CONTINUE WITH UM1100.
OTHERWISE, GO TO EOS.
UM1100.Now let’s talk about over-the-counter medications, and nonprescription vitamins, minerals, herbals, and
other dietary supplements that you have given your child. {Please show me any you have giving your child
since {he/she} was born./Please tell me the names of the nonprescription medications and nonprescription
vitamins, minerals, herbals, and supplements that you have given your child since {he/she} was born.}. Overthe-counter medications include products you buy without a doctor’s prescription and may give to your child for a
cold or cough, fever, or fussiness or irritability.
PROBE: Have you given any other over-the-counter medications or nonprescription vitamins, minerals, herbals,
or other dietary supplements to your child since {he/she} was born that we missed?
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER.
ACTIVATE LOOKUP AND SELECT MEDICATIONS FROM LIST. CHECK TO MAKE SURE THAT BOTH THE
BRAND AND TYPE OR FORMULA MATCH. IF A MEDICATION IS NOT ON LIST, ENTER THE FULL NAME
(INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
CONFIRM ALL MEDICATIONS ENTERED BEFORE MOVING TO NEXT SCREEN.
SHOW CARD UM1.
PRODUCT ON MEDICINE LIST .............................................................. 1
PRODUCT NOT ON LIST (SPECIFY): __________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–42
Version 1/20/08
Visit Type: 6 Month
Target: Mother
BEGIN LOOP UM02
LOOP:
CYCLE THROUGH UM1200–UM1700 FOR EACH OTC.
UM1200.{First/Next}, let’s talk about {PRODUCT}.
UM1300.WAS PRODUCT LABEL SEEN?
YES ..........................................................................................................
NO ............................................................................................................
1
2
UM1400.RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK:
How is this {PRODUCT} taken:
By mouth, ................................................................................................. 01
Inhaled either by mouth or nose, .............................................................. 02
Injected,.................................................................................................... 03
Applied to the skin, such as a patch or creams, or ................................... 04
Some other way? (SPECIFY): _________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM1500.When did you start giving your child {PRODUCT}:
Within the last month, ............................................................................... 1
1–3 months ago, or .................................................................................. 2
More than 3 months ago?......................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
UM1600.Since {CHILD} was born, how often have you given your child {PRODUCT}:
Less than once a month, .......................................................................... 01
Once a month,.......................................................................................... 02
2–3 times a month (but less than once a week), ...................................... 03
1–2 times a week, .................................................................................... 04
3–4 times a week, .................................................................................... 05
5–6 times a week, or ................................................................................ 06
Every day? ............................................................................................... 07
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
UM1700.Are you still giving {CHILD} {PRODUCT}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–43
Version 1/20/08
Visit Type: 6 Month
Target: Mother
END LOOP UM02
LOOP:
CYCLE THROUGH UM1200–UM1700 FOR THE NEXT OTC IN ROSTER.
WHEN FINISHED WITH ALL OTCS LISTED IN ROSTER CONTINUE WITH
NEXT SECTION.
Appendix A
A.1.4.b–44
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: Alternative/Traditional Medicines
AM0100.The next questions ask about traditional medicines, home remedies, and beauty products made in other countries
and sent to the United States.
AM0200.Since your baby was born, did you give your child any traditional medicines or home remedies to treat stomach
ache, vomiting, colic, empacho (stomach ache or vomiting), or to aid digestion?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (AM0500)
REFUSED .......................................................................................... 9--97 (AM0500)
DON’T KNOW .................................................................................... 9--98 (AM0500)
AM0300.Which traditional medicines or home remedies have you given your child?
SELECT ALL THAT APPLY.
SHOW CARD PR2.
ALBAYALDE (ALBAYAIDLE) ................................................................... 01
AZARCON (RUEDA, CORAL, MARIA LUISA, ALARCON, LIGA, LUIGA) . 02
BALI GOLI ................................................................................................ 03
GHASARD................................................................................................ 04
GRETA ..................................................................................................... 05
KANDU..................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 94
OTHER (SPECIFY): _________________________________________ 95
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HELP SCREEN:
Albayalde: Albayalde is a white powder also known as albayaidle that comes from Mexico, Cuba, Puerto Rico, or
other parts of Central or South America that is sometimes given to children for colic or empacho (stomach ache or
vomiting).
Azarcon: Azarcon is a bright red-orange powder also known as Rueda, Coral, Maria Luisa, Alarcon, Liga, or Luiga
that comes from Mexico, Cuba, Puerto Rico, or other parts of Central or South America that is sometimes given to
children for colic or empacho (stomach ache or vomiting).
Bali Goli: Bali Goli is a round, flat bean given in “gripe” water that comes from India or Southeast Asia that is
sometimes given to children for colic, stomach ache, or to aid digestion.
Ghasard: Ghasard is a brown powder that comes from India or Southeast Asia that is sometimes given to children
for colic, stomach ache, or to aid digestion.
Greta: Greta is a yellow powder that comes from Mexico, Cuba, Puerto Rico, or other parts of Central or South
America that is sometimes given to children for colic or empacho (stomach ache or vomiting).
Kandu: Kandu is a red powder that comes from India or Southeast Asia that is sometimes given to children for
colic, stomach ache, or to aid digestion.
Appendix A
A.1.4.b–45
Version 1/20/08
Visit Type: 6 Month
Target: Mother
BEGIN LOOP PR01
LOOP:
FOR EACH YES RESPONSE IN AM0300, ASK AM0400.
AM0400.How often did you give your child {READ NAME OF YES RESPONSE}?
Once a month or less ............................................................................... 1
2–3 times a month.................................................................................... 2
Once a week ............................................................................................ 3
2–3 times a week ..................................................................................... 4
4–6 times a week ..................................................................................... 5
Every day ................................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP PR01
LOOP:
IF MORE YES RESPONSES, ASK AM0400 AGAIN.
IF AM0400 ASKED FOR ALL YES RESPONSES IN AM0300, END LOOP.
AM0500 Since your baby was born, did you give your child any traditional medicines or home remedies to treat a skin
condition or rash?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (AM0800)
REFUSED .......................................................................................... 9--97 (AM0800)
DON’T KNOW .................................................................................... 9--98 (AM0800)
AM0600.Which traditional medicines or home remedies have you given your child?
SELECT ALL THAT APPLY.
SHOW CARD PR3.
KOHL (ALKOHL, TIRO, SURMA, SAOTT)............................................... 01
LITARGIRIO ............................................................................................. 02
PAYLOOAH (PEJLUAM, PE LUA) ........................................................... 03
OTHER (SPECIFY): _________________________________________ 94
OTHER (SPECIFY): _________________________________________ 95
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–46
Version 1/20/08
Visit Type: 6 Month
Target: Mother
HELP SCREEN:
Kohl: Kohl is a black powder also called Alkohl, Tir, Surma, or Saott that comes from India, Pakistan, the Middle
East or Africa that is sometimes used on a child’s belly button (umbilical cord) to treat an injury or skin infection.
Litargirio: Litargirio is a yellow- or peach-colored powder that comes from Mexico, Cuba, Puerto Rico, or other
parts of Central or South America that is used as a deodorant or foot powder or as a treatment for burns, cuts,
and other conditions.
Paylooah: Paylooah comes from India or Southeast Asia and is sometimes used to treat a rash, fever, or other
condition.
BEGIN LOOP PR02
LOOP:
FOR EACH YES RESPONSE IN AM0600, ASK AM0700.
AM0700.How often did you give your child {READ NAME OF YES RESPONSE}?
Once a month or less ............................................................................... 1
2–3 times a month.................................................................................... 2
Once a week ............................................................................................ 3
2–3 times a week ..................................................................................... 4
4–6 times a week ..................................................................................... 5
Every day ................................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP PR02
LOOP:
IF MORE YES RESPONSES, ASK AM0700 AGAIN.
IF AM0700 ASKED FOR ALL YES RESPONSES IN AM0600, END LOOP.
AM0800.Since your baby was born, did you give your child any traditional medicines or home remedies to treat a fever or
infection?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (AM1100)
REFUSED .......................................................................................... 9--97 (AM1100)
DON’T KNOW .................................................................................... 9--98 (AM1100)
Appendix A
A.1.4.b–47
Version 1/20/08
Visit Type: 6 Month
Target: Mother
AM0900.Which traditional medicines or home remedies have you given your child?
SELECT ALL THAT APPLY.
SHOW CARD PR4.
KOHL (ALKOHL, TIRO, SURMA, SAOTT)............................................... 01
PAYLOOAH (PEJLUAM, PE LUA) ........................................................... 02
OTHER (SPECIFY): _________________________________________ 94
OTHER (SPECIFY): _________________________________________ 95
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HELP SCREEN:
Kohl: Kohl is a black powder also called Alkohl, Tir, Surma, or Saott that comes from India, Pakistan, the Middle
East or Africa that is sometimes used on a child’s belly button (umbilical cord) to treat an injury or skin infection.
Paylooah: Paylooah comes from India or Southeast Asia and is sometimes used to treat a rash, fever, or other
condition.
BEGIN LOOP PR03
LOOP:
FOR EACH YES RESPONSE IN AM0900, ASK AM1000.
AM1000.How often did you give your child {READ NAME OF YES RESPONSE}?
Once a month or less ............................................................................... 1
2–3 times a month.................................................................................... 2
Once a week ............................................................................................ 3
2–3 times a week ..................................................................................... 4
4–6 times a week ..................................................................................... 5
Every day ................................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP PR03
LOOP:
IF MORE YES RESPONSES, ASK AM1000 AGAIN.
IF AM1000 ASKED FOR ALL YES RESPONSES IN AM0900, END LOOP.
AM1100.Since your baby was born, did you give your child any traditional medicines or home remedies for any other
reason?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
Appendix A
A.1.4.b–48
Version 1/20/08
Visit Type: 6 Month
Target: Mother
AM1200.Which traditional medicines or home remedies have you given your child?
SELECT ALL THAT APPLY.
SHOW CARD PR5.
ALBAYALDE (ALBAYAIDLE) ................................................................... 01
AZARCON (RUEDA, CORAL, MARIA LUISA, ALARCON, LIGA, LUIGA) . 02
BALI GOLI ................................................................................................ 03
GHASARD................................................................................................ 04
GRETA ..................................................................................................... 05
KANDU..................................................................................................... 06
LITARGIRIO ............................................................................................. 02
KOHL (ALKOHL, TIRO, SURMA, SAOTT)............................................... 01
PAYLOOAH (PEJLUAM, PE LUA) ........................................................... 02
OTHER (SPECIFY): _________________________________________ 94
OTHER (SPECIFY): _________________________________________ 95
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BEGIN LOOP PR04
LOOP:
FOR EACH YES RESPONSE IN AM1200, ASK AM1300 AND AM1400.
AM1300.What was the reason you gave your child {READ NAME OF YES RESPONSE}?
_________________________________________________________
REASON
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
AM1400.How often did you give your child {READ NAME OF YES RESPONSE}?
Once a month or less ............................................................................... 1
2–3 times a month.................................................................................... 2
Once a week ............................................................................................ 3
2–3 times a week ..................................................................................... 4
4–6 times a week ..................................................................................... 5
Every day ................................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–49
Version 1/20/08
Visit Type: 6 Month
Target: Mother
END LOOP PR04
LOOP:
IF MORE YES RESPONSES, ASK AM1300-AM1400 AGAIN.
IF AM1300-AM1400 ASKED FOR ALL YES RESPONSES IN AM1200, END
LOOP.
Appendix A
A.1.4.b–50
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: Product Use
PR0100. These questions ask about some different types of products you may have used to take care of yourself, your
family, or your home. Please choose your answer from one of these categories.
SHOW CARD PR1.
PR0200. Since your baby was born, how often have the following products been used in your home:
SHOW CARD PR1.
LESS
ABOUT
1–3
THAN
A FEW ONCE TIMES
ONCE
EVERY TIMES
A
A
A
DAY A WEEK WEEK MONTH MONTH
a. Bleach? ..........................................
b. Disinfectants other than bleach,
such as Lysol? ...............................
c. Window or glass cleaner? ..............
d. Carpet cleaner?..............................
e. Any type of air fresheners including
spray, stick, aerosol, or plug-in?.....
f. Other aerosols or sprays of any
kind, including hair spray?..............
g. Paint or varnish? ............................
h. Turpentine, mineral spirits, or
paint thinner? .................................
i. Other types of paint stripper? .........
NOT
AT ALL
RF
DK
01
02
03
04
05
06
9--97 9--98
01
01
01
02
02
02
03
03
03
04
04
04
05
05
05
06
06
06
9--97 9--98
9--97 9--98
9--97 9--98
01
02
03
04
05
06
9--97 9--98
01
01
02
02
03
03
04
04
05
05
06
06
9--97 9--98
9--97 9--98
01
01
02
02
03
03
04
04
05
05
06
06
9--97 9--98
9--97 9--98
PR0300. Since your baby was born, about how often have candles or incense been burned inside your home?
Every day, ................................................................................................ 01
A few times a week, ................................................................................. 02
About once a week, .................................................................................. 03
1–3 times a month, .................................................................................. 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–51
Version 1/20/08
Visit Type: 6 Month
Target: Mother
PR0400. Since your baby was born, about how often have you used scented products for your home such as scented
laundry detergents, fabric softener, or dish soaps? Do not include air fresheners, candles, or incense.
Every day, ................................................................................................ 01
A few times a week, ................................................................................. 02
About once a week, .................................................................................. 03
1-3 times a month, ................................................................................... 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR0500. The next questions ask about the types of diapers you use on your child.
PR0600.Since your baby was born, about how often did you put each of the following types of diapers on your child?
Fill in one circle for each statement that describes a type of diaper.
NEVER
Disposable diapers.........................
Cloth diapers cleaned by a
professional diaper service...........
Cloth diapers cleaned at home.......
ABOUT
HALF OF
SOMETIMES THE TIME
MOST OF
THE TIME
ALWAYS RF
DK
1
2
3
4
5
9--97 9--98
1
1
2
2
3
3
4
4
5
5
9--97 9--98
9--97 9--98
PR0700. Since your baby was born, about how often did you use each of the following types of baby wipes on your child?
Fill in one circle for each statement that describes a type of baby wipe.
NEVER
Scented Baby Wipes ........................................
Unscented Baby Wipes ....................................
1
1
OCCASIONALLY
2
2
OFTEN ALWAYS
3
3
PR0900. Does {CHILD} use a pacifier?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX PR01)
REFUSED .......................................................................................... 9--97 (BOX PR01)
DON’T KNOW .................................................................................... 9--98 (BOX PR01)
PR1000.How many hours a day does {CHILD} use {his/her} pacifier?
Less than 1 hour,...................................................................................... 1
1–2 hours, ................................................................................................ 2
2–5 hours, or ............................................................................................ 3
6 or more hours? ...................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
4
4
RF
DK
9--97 9--98
9--97 9--98
Appendix A
A.1.4.b–52
Version 1/20/08
Visit Type: 6 Month
Target: Mother
BOX PR01
CHECK ITEM:
IF R NEVER BREASTFED, GO TO PR1300.
OTHERWISE, CONTINUE.
PR1100.Since your baby was born, about how often did you put a breast nipple cream, salve, or balm on your nipples to
prevent or treat sore or tender nipples?
Every day when breastfeeding, ................................................................ 01
A few times a week when breastfeeding, ................................................. 02
About once a week when breastfeeding,.................................................. 03
1–3 times a month when breastfeeding.................................................... 04
Less than once a month when breastfeeding, or...................................... 05
Not at all? ................................................................................................. 06 (PR1000)
REFUSED .......................................................................................... 9--97 (PR1000)
DON’T KNOW .................................................................................... 9--98 (PR1000)
PR1200.Which of the following types of breast nipple cream, salve, or balm did you use most often on your breasts?
A petroleum based product such as Vaseline, ......................................... 01
A lanolin based product, ........................................................................... 02
Soothing gel pads, or .............................................................................. 03
Other type of product? (SPECIFY):)_____________________________ 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR1300.Since your baby was born, about how often have you used any insect repellent spray, lotion, or towelettes on
{CHILD}?
Every day, ................................................................................................ 01
A few times a week, ................................................................................. 02
About once a week, .................................................................................. 03
1–3 times a month, .................................................................................. 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR1400.Did the insect repellent contain DEET? (DEET is usually listed next to the name of the product or in the ingredient
list on the label.)
YES .......................................................................................................... 1
NO ............................................................................................................ 2
USED BOTH REPELLENT WITH DEET AND WITHOUT DEET ............. 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–53
Version 1/20/08
Visit Type: 6 Month
Target: Mother
PR1500.Since your baby was born, have you treated {CHILD} or other people in your home for lice or scabies?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
PR1600.Who did you treat, was it {CHILD}, someone else, or both?
BABY........................................................................................................ 1
SOMEONE ELSE..................................................................................... 2
BOTH BABY AND SOMEONE ELSE .......................................................
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR1700.What product did you use to treat lice or scabies?
PROBE: Anything else?
SELECT ALL THAT APPLY.
NIX ........................................................................................................... 01
RID ........................................................................................................... 02
GENERIC/DRUGSTORE BRAND LICE/SCABIES PRODUCT................ 03
ELIMITE ................................................................................................... 04
ACTICIN ................................................................................................... 05
EURAX ..................................................................................................... 06
KWELL/KWELLEDA................................................................................. 07
OVIDE ...................................................................................................... 08
STROMECTOL ........................................................................................ 09
OTHER (SPECIFY: _________________________________________ 94
OTHER (SPECIFY: _________________________________________ 95
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–54
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: In-Home Exposures
EX0100. Now I’d like to ask about any pets you may have in your home.
EX0200. Are there any pets that spend any time inside your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EX0900)
REFUSED .......................................................................................... 9--97 (EX0900)
DON’T KNOW .................................................................................... 9--98 (EX0900)
EX0300.What kind of pets are these?
SELECT ALL THAT APPLY.
DOG ......................................................................................................... 01
CAT .......................................................................................................... 02
SMALL MAMMAL (RABBIT, GERBIL, HAMSTER, GUINEA PIG,
FERRET, MOUSE)................................................................................ 03
BIRD......................................................................................................... 04
FISH OR REPTILE (TURTLE, SNAKE, LIZARD)..................................... 05
OTHER (SPECIFY): _________________________________________ 94
OTHER (SPECIFY): _________________________________________ 95
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX0400. Are any products ever used on your pets to control fleas, ticks, or mites? This includes flea collars, flea and tick
powders, shampoos, or other flea, tick and mite control products. (This does not include pills given to your pet to
control for fleas or other insects.)
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EX0700)
REFUSED .......................................................................................... 9--97 (EX0700)
DON’T KNOW .................................................................................... 9--98 (EX0700)
EX0500. When were any of these last used on any of your pets:
Within the last month, ............................................................................... 1
1–3 months ago,....................................................................................... 2
4–6 months ago, or .................................................................................. 3
More than 6 months ago?......................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–55
Version 1/20/08
Visit Type: 6 Month
Target: Mother
EX0600. What are the names of the products used on your pets to control fleas, ticks, or mites? Please show me the
products or containers if you have them.
_______________________________
ENTER PRODUCT NAME FROM LIST
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
EX0700. Do any of your pets go in the room where your baby sleeps most of the time?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX0800. Do any of your pets sleep on the same bedding as your baby?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX0900. What temperature did you use to wash your child’s sheets? Was it,
HOT.......................................................................................................... 1
WARM ...................................................................................................... 2
COLD ...................................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX1000. About how often do you wash your child’s clothes, towels, bedding, or other laundry with each of the following
items? Fill in one circle for each item listed.
LESS
ABOUT
1-3
THAN
A FEW ONCE TIMES
ONCE
EVERY TIMES
A
A
A
NOT
DAY A WEEK WEEK MONTH MONTH AT ALL RF
DK
Liquid or powder laundry soap with a
fragrance (such as lemon scent,
mountain spring, floral, clean
breeze, or other scent) ....................
Chlorine Bleach ..................................
Fabric softener or dryer sheet with
a fragrance (such as lemon scent,
mountain spring, floral, clean
breeze, or other scent) ....................
Spot or stain remover .........................
1
1
2
2
3
3
4
4
5
5
6
6
9--97 9--98
9--97 9--98
1
1
2
2
3
3
4
4
5
5
6
6
9--97 9--98
9--97 9--98
Appendix A
A.1.4.b–56
Version 1/20/08
Visit Type: 6 Month
Target: Mother
EX1100. Do you use any methods to “allergy-proof” your home? Please answer “yes” or “no” to each method I describe.
YES
NO
RF
DK
1
2
9--97
9--98
1
1
1
1
2
2
2
2
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
a. Tannic acid or other mite control chemicals? .......................................
b. Impermeable mattress and or pillow covers on your child’s bed
or crib? .................................................................................................
c. Use a special vacuum such as a HEPA vacuum?................................
d. Intentionally removed rugs or upholstered furniture? ...........................
e. Any other methods? (SPECIFY): _____________________________
EX1200. Does your furnace or air conditioning system use a special HEPA (High Efficiency Particulate Air) or other type of
allergy filter to filter the air?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX1300. Thinking about the past 7 days, approximately how many hours a day did you keep the windows or doors open in
your home (for ventilation or to let air in)? Was it:
Less than 1 hour per day,......................................................................... 1
1–3 hours per day, ................................................................................... 2
4–12 hours per day, ................................................................................. 3
More than 12 hours per day, or ................................................................ 4
Not at all? ................................................................................................. 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX1400. I would now like to ask about products that may have been used in your home or yard to control for ants, termites,
cockroaches, bees, wasps, moths, or other insects during the past 6 months.
EX1500. When were any pesticides last used inside or outside your home to control for insects?
Within the last month, ............................................................................... 1
1–3 months ago,....................................................................................... 2
4–6 months ago,....................................................................................... 3
More than 6 months ago, or ..................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(EX2000)
(EX2000)
(EX2000)
(EX2000)
Appendix A
A.1.4.b–57
Version 1/20/08
Visit Type: 6 Month
Target: Mother
EX1600. In preparation for this interview, we asked that you gather together the pesticide cans or containers that have
been used in the last 6 months. You may also have letters from building maintenance about pesticide application,
or receipts from the exterminator that list which products were used. Please show me, or tell me the names of the
products that have been used within the last 6 months, either indoors or outdoors, to treat for insects?
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT, LETTER, OR RECEIPT IS PROVIDED.
_________________________
PRODUCT NAME FROM LIST
_________________________
REGISTRATION NUMBER IF KNOWN
REFUSED .................................................................................. 9--97 (EOS)
DON’T KNOW ............................................................................ 9--98 (EOS)
BEGIN LOOP EX01
LOOP:
CYCLE THROUGH EX1700–EX1900 FOR ALL INSECTICIDE PRODUCTS
LISTED IN EX1600.
EX1700. How was the {PRODUCT} applied?
SELECT ALL THAT APPLY.
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT IS PROVIDED.
SPRAY ..................................................................................................... 01
BOMB....................................................................................................... 02
POWDER ................................................................................................. 03
STRIP....................................................................................................... 04
MOTH BALLS........................................................................................... 05
FOAM ....................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–58
Version 1/20/08
Visit Type: 6 Month
Target: Mother
EX1800.Which of the following areas of your home were treated with {PRODUCT}? Was it…
INTERVIEWER INSTRUCTION:
SELECT “NA” FOR EACH ROOM OR AREA R REPORTS THAT THEY DO NOT HAVE.
a. The common living area, that is the room other than
bedroom or kitchen where you spend most of your time?......
b. The kitchen? ..........................................................................
c. Your bedroom? ......................................................................
d. The basement? ......................................................................
e. Any other rooms?...................................................................
f. Outdoors, around the walls of your house or building? ..........
g. Outdoors, in the garden or yard? ...........................................
h. (IF R LIVES IN SINGLE FAMILY HOME, RECORD “NA”
WITHOUT ASKING) Common areas inside building but
outside of your home or apartment (public foyer or
hallway, etc.)? ........................................................................
YES
NO
NA
RF
DK
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
1
2
3
9--97
9--98
EX1900. How often was the {PRODUCT} used in the past 6 months:
More than once a month, or ..................................................................... 1
Once a month or less? ............................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP EX01
LOOP:
CYCLE THROUGH EX1700–EX1900 FOR NEXT INSECTICIDE PRODUCT.
IF NO MORE PRODUCTS, GO TO EX2000.
EX2000. Since your baby was born, have you seen signs of mice, rats, or other rodents in your home (not including pets)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX2100. Since your baby was born, have you seen cockroaches in your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX2200. Water damage is a common problem that occurs inside of many homes. Water damage includes water stains on
the ceiling or walls, rotting wood, and flaking sheetrock or plaster. This damage may be from broken pipes, a
leaky roof, or floods.
Appendix A
A.1.4.b–59
Version 1/20/08
Visit Type: 6 Month
Target: Mother
EX2300. Since your baby was born, have you seen any water damage inside your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX2400. Since your baby was born, have you seen any mold or mildew on walls or other surfaces, other than the shower
or bathtub, inside your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EX2600)
REFUSED .......................................................................................... 9--97 (EX2600)
DON’T KNOW .................................................................................... 9--98 (EX2600)
EX2500. In which rooms have you seen the mold or mildew?
PROBE: Any other rooms?
SELECT ALL THAT APPLY.
KITCHEN.................................................................................................. 01
LIVING ROOM ......................................................................................... 02
HALL/LANDING ....................................................................................... 03
RESPONDENT’S BEDROOM.................................................................. 04
OTHER BEDROOM ................................................................................. 05
BATHROOM/TOILET ............................................................................... 06
BASEMENT.............................................................................................. 07
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX2600. The next few questions ask about any recent additions or renovations to your home.
EX2700. Since your baby was born, have any additions been built onto your home to make it bigger?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX2800. Since your baby was born, have any renovations or other construction been done in your home? Include only
major projects. Do not count smaller projects that were just painting or wall papering.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EX3000)
REFUSED .......................................................................................... 9--97 (EX3000)
DON’T KNOW .................................................................................... 9--98 (EX3000)
Appendix A
A.1.4.b–60
Version 1/20/08
Visit Type: 6 Month
Target: Mother
EX2900. Which rooms were renovated?
PROBE: Any others?
SELECT ALL THAT APPLY.
KITCHEN.................................................................................................. 01
LIVING ROOM ......................................................................................... 02
HALL/LANDING ....................................................................................... 03
RESPONDENT’S BEDROOM.................................................................. 04
OTHER BEDROOM ................................................................................. 05
BATHROOM/TOILET ............................................................................... 06
BASEMENT.............................................................................................. 07
OTHER (SPECIFY): _________________________________________ 08
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX3000. Now I’d like to ask about the water in your home.
EX3100. What water source in your home do you use most of the time for drinking:
Tap water, ................................................................................................ 1
Filtered tap water,..................................................................................... 2
Bottled water, or ....................................................................................... 3
Some other source? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX3200. What water source in your home is used most of the time for cooking:
Tap water, ................................................................................................ 1
Filtered tap water,..................................................................................... 2
Bottled water, or ....................................................................................... 3
Some other source? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX3300. Now, a couple of questions about your neighborhood.
EX3400. In your opinion, is your neighborhood…
A very good place to live, ......................................................................... 1
A fairly good place to live,......................................................................... 2
Not a very good place to live, or ............................................................... 3
Not at all a good place to live? ................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–61
Version 1/20/08
Visit Type: 6 Month
Target: Mother
EX3500. Do you feel that your neighborhood is…
Very safe, ................................................................................................. 1
Somewhat safe,........................................................................................ 2
Somewhat unsafe, or ............................................................................... 3
Very unsafe? ............................................................................................ 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–62
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: Occupation and Take Home Exposures
OX0100. Next, I’d like to ask about some questions about work.
OX0200. Before you gave birth to your baby, were you employed at a job or business?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (OX0400)
REFUSED .......................................................................................... 9--97 (OX0400)
DON’T KNOW .................................................................................... 9--98 (OX0400)
OX0300. Have you returned to work, or are you currently on maternity leave from this job? Please look at this card and tell
me which category best describes your work situation.
SHOW CARD OX1.
RETURNED TO WORK ........................................................................... 1
UNPAID LEAVE ....................................................................................... 2
PAID LEAVE ............................................................................................ 3
LEFT THE POSITION .............................................................................. 4
LOOKING FOR WORK ............................................................................ 5
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OX0400. When do you plan to {return to work/start a new job or business}? Would you say:
Within one month, .................................................................................... 1
Between 1 and 3 months,......................................................................... 2
Between 4 and 6 months, or..................................................................... 3
More than 6 months ................................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OX0500. When you return to work, do you intend to work full-time or part-time?
FULL-TIME............................................................................................... 1
PART-TIME .............................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX OX01
CHECK ITEM:
IF OX0300 = “1,” CONTINUE WITH OX0600.
OTHERWISE, GO TO OX0900.
(BOX OX01)
(OX0500)
(OX0500)
(OX0500)
Appendix A
A.1.4.b–63
Version 1/20/08
Visit Type: 6 Month
Target: Mother
OX0600. On what date did you return to work?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OX0700. Are you currently working full-time or part-time?
FULL-TIME............................................................................................... 1 (OX0900)
PART-TIME .............................................................................................. 2
REFUSED .......................................................................................... 9--97 (OX0900)
DON’T KNOW .................................................................................... 9--98 (OX0900)
OX0800. How many hours per week do you work?
|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OX0900. Now I am going to ask you about work clothing. Some people work at jobs where their skin, clothes, or shoes get
dirty or stained. Think about everyone in your household. Does anyone ever routinely come home with dirty or
stained skin, work clothes, or shoes? By “dirty or stained” I mean their skin or clothes have dust, grease, or other
visible chemical spots on them.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
OX1000. Who is it that comes home with dirty or stained skin, work clothes, or shoes? Is it:
You, .......................................................................................................... 1
Others in the home, or.............................................................................. 2
Both you and others in the home?............................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OX1100. How often do you or anyone in your household come home from work with dirty hands or skin?
Every day, ............................................................................................... 1
5–6 times a week, .................................................................................... 2
3–4 times a week, .................................................................................... 3
1–2 times a week, or ................................................................................ 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–64
Version 1/20/08
Visit Type: 6 Month
Target: Mother
OX1200. How often do you or anyone in your household wear dirty work shoes inside your home?
Every day, ............................................................................................... 1
5–6 times a week, .................................................................................... 2
3–4 times a week, .................................................................................... 3
1–2 times a week, or ................................................................................ 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OX1300. How often do you or anyone in your household wear dirty work clothes inside your home?
Every day, ................................................................................................ 1
5–6 times a week, .................................................................................... 2
3–4 times a week, .................................................................................... 3
1–2 times a week, or ................................................................................ 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OX1400. How often do you or anyone in your household wash work clothes at home?
Every day, ................................................................................................ 1
5–6 times a week, .................................................................................... 2
3–4 times a week, .................................................................................... 3
1–2 times a week, or ................................................................................ 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OX1500. Are work clothes washed separately from other clothes?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(OX1600)
(OX1600)
(OX1600)
(OX1600)
Appendix A
A.1.4.b–65
Version 1/20/08
Visit Type: 6 Month
Target: Mother
OX1600. What types of materials have you or anyone in your household brought home on work clothes or shoes?
SHOW CARD OX2.
SELECT ALL THAT APPLY.
DIRT ......................................................................................................... 01
WOOD DUST ........................................................................................... 02
GREASE .................................................................................................. 03
PESTICIDES ............................................................................................ 04
METAL DUST........................................................................................... 05
COAL OR MINING DUST......................................................................... 06
ANIMAL HAIR .......................................................................................... 07
FIBERS (SUCH AS ASBESTOS OR FIBERGLASS) ............................... 08
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–66
Version 1/20/08
Visit Type: 6 Month
Target: Mom
6-Month Visit: Maternal Depression
MD001. Now, I will read a list of the ways you might have felt or behaved in the past 7 days. Please look at this card, and
tell me how often you have felt or thought a certain way.
SHOW CARD MD1.
MD002. You were bothered by things that usually don’t bother you.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD003. You did not feel like eating; your appetite was poor.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD004. You felt that you could not shake off the blues even with the help of your family or friends.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–67
Version 1/20/08
Visit Type: 6 Month
Target: Mom
MD005. You felt you were just as good as other people.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD006. You had trouble keeping your mind on what you were doing.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD007. You felt depressed.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD008. You felt that everything you did was an effort.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–68
Version 1/20/08
Visit Type: 6 Month
Target: Mom
MD009. You felt hopeful about the future.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD010. You thought your life had been a failure.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD011. You felt fearful.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD012. Your sleep was restless.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–69
Version 1/20/08
Visit Type: 6 Month
Target: Mom
MD013. You were happy.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD014. You talked less than usual.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD015. You felt lonely.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD016. People were unfriendly.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–70
Version 1/20/08
Visit Type: 6 Month
Target: Mom
MD017. You enjoyed life.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD018. You had crying spells.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD019. You felt sad.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MD020. You felt that people dislike you.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–71
Version 1/20/08
Visit Type: 6 Month
Target: Mom
MD021. You could not get “going.”
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONCE A WEEK) ........ 1
SOME OR A LITTLE OF THE TIME (1–2 DAYS A WEEK) ..................... 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME
(3–4 DAYS A WEEK) ............................................................................... 3
MOST OR ALL OF THE TIME (5–7 DAYS A WEEK)............................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–72
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: Social Support
SS0100. The following statements are about the help and support you have. Please look at the card, and for each
statement, tell me which category best describes how you feel.
SHOW CARD SS1.
SS0200. You have no one to share your feelings with.
SHOW CARD SS1.
THIS IS EXACTLY HOW I FEEL............................................................. 1
THIS IS OFTEN HOW I FEEL .................................................................. 2
THIS IS HOW I SOMETIMES FEEL......................................................... 3
I NEVER FEEL THIS WAY....................................................................... 4
DON’T HAVE A PARTNER ...................................................................... 5
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
SS0300. Your partner provides the emotional support you need.
SHOW CARD SS1.
THIS IS EXACTLY HOW I FEEL............................................................. 1
THIS IS OFTEN HOW I FEEL .................................................................. 2
THIS IS HOW I SOMETIMES FEEL......................................................... 3
I NEVER FEEL THIS WAY....................................................................... 4
DON’T HAVE A PARTNER ...................................................................... 5
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
SS0400. There are other mothers with whom you can share your experiences.
SHOW CARD SS1.
THIS IS EXACTLY HOW I FEEL.............................................................. 1
THIS IS OFTEN HOW I FEEL .................................................................. 2
THIS IS HOW I SOMETIMES FEEL......................................................... 3
I NEVER FEEL THIS WAY....................................................................... 4
DON’T HAVE A PARTNER ...................................................................... 5
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–73
Version 1/20/08
Visit Type: 6 Month
Target: Mother
SS0500. You believe in moments of difficulty, your neighbors would help you.
SHOW CARD SS1.
THIS IS EXACTLY HOW I FEEL.............................................................. 1
THIS IS OFTEN HOW I FEEL .................................................................. 2
THIS IS HOW I SOMETIMES FEEL......................................................... 3
I NEVER FEEL THIS WAY....................................................................... 4
DON’T HAVE A PARTNER ...................................................................... 5
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
SS0600. You are worried that your partner might leave you.
SHOW CARD SS1.
THIS IS EXACTLY HOW I FEEL.............................................................. 1
THIS IS OFTEN HOW I FEEL .................................................................. 2
THIS IS HOW I SOMETIMES FEEL......................................................... 3
I NEVER FEEL THIS WAY....................................................................... 4
DON’T HAVE A PARTNER ...................................................................... 5
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
SS0700. There is always someone with whom you can share your happiness and excitement about your baby.
SHOW CARD SS1.
THIS IS EXACTLY HOW I FEEL.............................................................. 1
THIS IS OFTEN HOW I FEEL .................................................................. 2
THIS IS HOW I SOMETIMES FEEL......................................................... 3
I NEVER FEEL THIS WAY....................................................................... 4
DON’T HAVE A PARTNER ...................................................................... 5
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
SS0800. If you feel tired, you can rely on your partner to take over.
SHOW CARD SS1.
THIS IS EXACTLY HOW I FEEL.............................................................. 1
THIS IS OFTEN HOW I FEEL .................................................................. 2
THIS IS HOW I SOMETIMES FEEL......................................................... 3
I NEVER FEEL THIS WAY....................................................................... 4
DON’T HAVE A PARTNER ...................................................................... 5
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–74
Version 1/20/08
Visit Type: 6 Month
Target: Mother
SS0900. If you were in financial difficulty, you know your family would help if they could.
SHOW CARD SS1.
THIS IS EXACTLY HOW I FEEL.............................................................. 1
THIS IS OFTEN HOW I FEEL .................................................................. 2
THIS IS HOW I SOMETIMES FEEL......................................................... 3
I NEVER FEEL THIS WAY....................................................................... 4
DON’T HAVE A PARTNER ...................................................................... 5
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
SS1000. If you were in financial difficulty, you know your friends would help if they could.
SHOW CARD SS1.
THIS IS EXACTLY HOW I FEEL.............................................................. 1
THIS IS OFTEN HOW I FEEL .................................................................. 2
THIS IS HOW I SOMETIMES FEEL......................................................... 3
I NEVER FEEL THIS WAY....................................................................... 4
DON’T HAVE A PARTNER ...................................................................... 5
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
SS1100. How much help would you say you have had with the following since having your baby? Please look at the card
and tell me how much help you have had with:
a.
b.
c.
d.
e.
f.
Shopping? .......................................................
Cleaning your home? ......................................
Preparing meals? ............................................
Doing dishes? .................................................
Changing diapers? ..........................................
Washing the clothes?......................................
A LOT
OF HELP
SOME
HELP
1
1
1
1
1
1
2
2
2
2
2
2
HARDLY NO HELP
ANY HELP AT ALL
3
3
3
3
3
3
SS1200. Overall, do you feel you have received:
Too much help.......................................................................................... 1
The right amount of help........................................................................... 2
Too little help ............................................................................................ 3
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
4
4
4
4
4
4
RF
DK
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
Appendix A
A.1.4.b–75
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: Financial Security
FS0100. The next few questions are about whether you feel you have enough money for yourself and the people in your
house
FS0200. At this time, do you feel you are able to afford a home suitable for yourself and your family?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS0300. Do you feel you are able to afford the furniture or household equipment that you need at this time?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS0400. Do you feel you are you able to afford the kind of car you need?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS0500. At this time, do you have enough money for the kind of food you think you and your family should have?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS0600. Do you have enough money for the kind of medical care you and your family should have?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS0700. At this time, do you have enough money for the kind of clothing you and your family should have?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–76
Version 1/20/08
Visit Type: 6 Month
Target: Mother
FS0800. Do you have enough money for the leisure activities you and your family want?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS0900. How difficult is it for you and your family to pay your bills?
Very difficult,............................................................................................. 1
Somewhat difficult, ................................................................................... 2
Not very difficult, or................................................................................... 3
Not difficult at all? ..................................................................................... 4
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS1000. At the end of the month, how much money would you say you end up with?
Not enough money, .................................................................................. 1
Just enough money, ................................................................................. 2
Some money left over, or ......................................................................... 3
A lot of money left over?........................................................................... 4
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS1400. Since your baby was born, did you receive benefits from the WIC program, that is, the Women, Infants and
Children program?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS1500. Since your baby was born, did you or any members of your household receive Food Stamps (which includes a
food stamp card or voucher, or cash grants from the state for food)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS1600. Since your baby was born, have you or any members of your household received TANF or welfare?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–77
Version 1/20/08
Visit Type: 6 Month
Target: Both
6-Month Visit: Household Composition and Demographics: Part 2
DM0100.These next questions are about the language spoken in your home.
DM0200.Is there any language other than English regularly spoken in your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (DM0700)
REFUSED .......................................................................................... 9--97 (DM0700)
DON'T KNOW .................................................................................... 9--98 (DM0700)
DM0300.What languages other than English are spoken in your home?
SELECT ALL THAT APPLY.
ARABIC .................................................................................................... 1
CHINESE ................................................................................................. 2
FILIPINO LANGUAGE ............................................................................. 3
FRENCH .................................................................................................. 4
GERMAN.................................................................................................. 5
GREEK..................................................................................................... 6
ITALIAN.................................................................................................... 7
JAPANESE............................................................................................... 8
KOREAN .................................................................................................. 9
POLISH .................................................................................................... 10
PORTUGUESE ........................................................................................ 11
SPANISH.................................................................................................. 12
VIETNAMESE .......................................................................................... 13
SIGN LANGUAGE.................................................................................... 14
SOME OTHER LANGUAGE (SPECIFY): ________________________ 96
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
DM0400.Is English also spoken in your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
BOX DM01
CHECK ITEM:
IF DM0300 HAS MORE THAN ONE LANGUAGE SELECTED OR DM0400 = 1
(ENGLISH ALSO SPOKEN IN HOME), CONTINUE WITH DM0500.
OTHERWISE, GO TO DM0600.
Appendix A
A.1.4.b–78
Version 1/20/08
Visit Type: 6 Month
Target: Both
DM0500.What is the primary language spoken in your home?
ENGLISH.................................................................................................. 0
ARABIC .................................................................................................... 1
CHINESE ................................................................................................. 2
FILIPINO LANGUAGE ............................................................................. 3
FRENCH .................................................................................................. 4
GERMAN.................................................................................................. 5
GREEK..................................................................................................... 6
ITALIAN.................................................................................................... 7
JAPANESE............................................................................................... 8
KOREAN .................................................................................................. 9
POLISH .................................................................................................... 10
PORTUGUESE ........................................................................................ 11
SPANISH.................................................................................................. 12
VIETNAMESE .......................................................................................... 13
SIGN LANGUAGE.................................................................................... 14
CANNOT CHOOSE.................................................................................. 15
SOME OTHER LANGUAGE (SPECIFY): ________________________ 96
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
DM0600.{How often do you use {{NON-ENGLISH LANGUAGE}/a language other than English} in speaking to your
{BABY?}/On average, how often do you use all languages, other than English, in speaking to {CHILD}?} Would
you say…
PROBE: We just need to know in general.
Never,....................................................................................................... 1
Sometimes, .............................................................................................. 2
Often, or .................................................................................................. 3
Very often? ............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
DM0700.Now I’m going to switch the subject and ask about health insurance.
DM0800.Do you currently have health insurance through a current or former employer or union, either through yourself or
another family member?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
DM0900.(Do you currently have:)
Insurance purchased directly from an insurance company (by yourself or another family member)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–79
Version 1/20/08
Visit Type: 6 Month
Target: Both
DM1000.(Do you currently have:)
Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a
disability?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
DM1100.(Do you currently have:)
TRICARE, VA, or other military health care?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
DM1200.(Do you currently have:)
Indian Health Service?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
DM1300.(Do you currently have:)
Medicare, for people 65 and older, or people with certain disabilities?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
DM1400.(Do you currently have:)
Any other type of health insurance or health coverage plan?
YES (SPECIFY): ___________________________________________ 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–80
Version 1/20/08
Visit Type: 6 Month
Target: Both
DM1500.Family income is important in analyzing the data we collect and is often used in scientific studies to compare
groups of people who are similar. Please remember that all the data you provide is confidential.
DM1600.Thinking about all {your/your family’s} sources of income, was your total family income in {LAST CALENDAR
YEAR} before taxes:
PROBE: Please note, a family is a group of two or more people who live together and who are related by birth,
marriage, or adoption.
$20,000 or more, or..................................................................................
Less than $20,000?..................................................................................
REFUSED ..........................................................................................
DON'T KNOW ....................................................................................
1
2
9--97
9--98
DM1700.Of these income groups, which category best represents {your/the total combined family} income during {LAST
CALENDAR YEAR}? Remember, a family is a group of two or more people who live together and who are related
by birth, marriage, or adoption.
Less than $4,999...................................................................................... 01
$5,000–$9,999 ......................................................................................... 02
$10,000–$19,999 ..................................................................................... 03
$20,000–$29,999 .....................................................................................
$30,000–$39,999 .....................................................................................
$40,000–$49,999 .....................................................................................
$50,000–$74,999 .....................................................................................
$75,000–$99,999 .....................................................................................
$100,000–$199,000 .................................................................................
$200,000 or more .....................................................................................
REFUSED ..........................................................................................
DON'T KNOW ....................................................................................
04
05
06
07
08
09
10
9--97
9--98
DM1800.Are there any other family members, not living in this household, who are also supported by this income?
YES ..........................................................................................................
NO ............................................................................................................
REFUSED ..........................................................................................
DON'T KNOW ....................................................................................
1
2 (EOS)
9--97 (EOS)
9--98 (EOS)
DM1900.How many other family members, not living in this household, are supported by this income?
|___|___|
NUMBER
REFUSED ..........................................................................................
DON'T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.b–81
Version 1/20/08
Visit Type: 6 Month
Target: Mother
6-Month Visit: Tracing Information
TR0100. Finally, I need to ask you a few questions so that staff from the National Children’s Study may contact you again.
TR0200. Sometimes if people move or change their telephone number, we have difficulty reaching them. Could I have the
names and telephone numbers of 1 or 2 friends or relatives not currently living with you who should know where
you could be reached in case we have trouble contacting you?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TR1100)
REFUSED .......................................................................................... 9--97 (TR1100)
DON'T KNOW .................................................................................... 9--98 (TR1100)
TR0300. I’d like to collect some basic contact information on this person/these people. What is the first person’s name?
INTERVIEWER INSTRUCTION:
CONFIRM SPELLING OF FIRST AND LAST NAMES.
________________
FIRST NAME
________________
LAST NAME
REFUSED ..........................................................................................
DON'T KNOW ....................................................................................
9--97 (TR1100)
9--98 (TR1100)
TR0400. What is his/her relationship to you?
MOTHER/FATHER .................................................................................. 01
BROTHER/SISTER.................................................................................. 02
AUNT/UNCLE .......................................................................................... 03
GRANDPARENT...................................................................................... 04
NEIGHBOR .............................................................................................. 05
FRIEND .................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–82
Version 1/20/08
Visit Type: 6 Month
Target: Mother
TR0500. What is his/her address?
INTERVIEWER INSTRUCTIONS:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________
STREET
_____________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON'T KNOW ....................................................................................
9--97
9--98
TR0600. What is his/her telephone number?
I__I__I__I – I__I__I__I – I__I__I__I__I
PHONE NUMBER
NONE .................................................................................................
REFUSED ..........................................................................................
DON'T KNOW ....................................................................................
9--91
9--97
9--98
TR0700. Now I’d like to collect information on a second contact. What is this person’s name?
INTERVIEWER INSTRUCTION:
CONFIRM SPELLING OF FIRST AND LAST NAMES.
______________
FIRST NAME
__________________
LAST NAME
REFUSED ..........................................................................................
DON'T KNOW ....................................................................................
9--97 (TR1100)
9--98 (TR1100)
TR0800. What is his/her relationship to you?
MOTHER/FATHER .................................................................................. 01
BROTHER/SISTER.................................................................................. 02
AUNT/UNCLE .......................................................................................... 03
GRANDPARENT...................................................................................... 04
NEIGHBOR .............................................................................................. 05
FRIEND .................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
Appendix A
A.1.4.b–83
Version 1/20/08
Visit Type: 6 Month
Target: Mother
TR0900 What is his/her address?
INTERVIEWER INSTRUCTIONS:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________
STREET
_____________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
REFUSED ..........................................................................................
DON'T KNOW ....................................................................................
9--97 (TR1100)
9--98
TR1000. What is his/her telephone number?
I__I__I__I – I__I__I__I – I__I__I__I__I
PHONE NUMBER
NONE .................................................................................................
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--91
9--97
9--98
TR1100 Finally, could you please tell me your Social Security Number or Individual Taxpayer Identification Number? The
National Children’s Study may use your Social Security Number to conduct health-related research by linking your
survey data with vital statistics and other health records. We also may use it if we need to locate you or your
family in the future. Except for these purposes, the Study will not release your Social Security Number to anyone,
including any government agency. Providing this information is voluntary. Whether or not you give us this number
will have no effect on any benefits you might receive. The National Children’s Study is authorized by the
Children’s Health Act of 2000 and the Public Health Service Act. (The Public Health Service Act authority is found
under Section 448 (42USC 285g).
INTERVIEWER INSTRUCTION:
CONFIRM IF KNOWN.
ENTER AS MUCH AS R KNOWS.
|___|___|___| |___|___| |___|___|___|___|
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TR1200. Thank you for answering these questions. This completes the interview portion of the visit.
Appendix A
A.1.4.c–1
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
9-Month Phone Call
TC0100. I’m calling today just to gather some information about you and {CHILD}.
TC2000. I’ll begin by asking about your baby’s personality and development. You may notice your baby’s personality
developing now that {he/she} is 9 months old. Overall, would you describe your baby as…
a.
b.
c.
d.
e.
f.
g.
Calm ...................................................................................................
Worried? .............................................................................................
Sociable or outgoing? .........................................................................
Angry? ................................................................................................
Shy or quiet? ......................................................................................
Stubborn? ...........................................................................................
Happy? ...............................................................................................
YES
NO
RF
DK
1
1
1
1
1
1
1
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
TC2200. I will read you a list of things your baby may already do or may start doing when {he/she} gets older. Does your
baby…
YES
NO
RF
DK
Follow you with {his/her} eyes? ................................................................
Smile when you smile at him/her?............................................................
Try to get a toy that is out of reach? .........................................................
Feed {him/herself} a cracker or cereal?....................................................
Wave goodbye? .......................................................................................
Reaches for toys or food held to him/her?................................................
Grab an object like a block or rattle from you? .........................................
Move a toy or block from one hand to the other? .....................................
Pick up a small object like a Cheerio or raisin? ........................................
Hold two toys or blocks at a time, one in each hand? ..............................
Startle or react to a sound? ......................................................................
Turns towards a sound? ...........................................................................
Turns toward someone when they’re speaking? ......................................
Makes sounds as though he/she is trying to speak? ................................
Says mama or dada? ...............................................................................
Can keep head steady when sitting or held up?.......................................
Rolls over from stomach to back? ............................................................
Rolls from back to stomach? ....................................................................
Sit up by {him/herself}? ............................................................................
Stand while holding onto something? .......................................................
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
Appendix A
A.1.4.c–2
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC2300. Next, I’d like to ask you about different types of child care {CHILD} may receive from someone other than parents
or guardians. This includes regularly scheduled care arrangements with relatives and non-relatives, and day care
or early childhood programs, whether or not there is a charge or fee, but not occasional baby-sitting.
TC2400. Does {CHILD} currently receive any regularly scheduled care from someone other than a parent or guardian, for
example from relatives, non-relatives, or a child care center or program?
Yes ........................................................................................................... 1
No............................................................................................................. 2 (TC2800)
REFUSED .......................................................................................... 9--97 (TC2800)
DON’T KNOW .................................................................................... 9--98 (TC2800)
TC2500. I’d like you to think about all the care {CHILD} receives from relatives, for example, from grandparents, brothers or
sisters, or any other relatives. This includes all regularly scheduled care arrangements with relatives that happen
at least weekly, but does not include occasional baby-sitting. Including all of these regular arrangements, how
many total hours each week does {CHILD} receive care from relatives?
|___|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC2600. I’d like you to think about all the regularly scheduled care your child receives on a weekly basis from non-relatives
in a home setting. This includes all regularly scheduled care arrangements with non-relatives that happen at least
weekly, including home child care providers, regularly scheduled sitter arrangements, or neighbors. This does not
include day care centers, early childhood programs, or occasional babysitting. Including all of these
arrangements, how many total hours each week does {CHILD} receive care from non-relatives in a home setting?
|___|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC2700. I’d like you to think about all the care your child receives from child care centers. For example, day care centers,
early learning centers, nursery schools, and preschools. This includes all regularly scheduled care arrangements
in child care centers that happen at least weekly. Including all of these arrangements, how many total hours each
week does {CHILD} receive care at child care centers?
|___|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.c–3
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC2800. Since {MONTH}, would you say {CHILD’s} health has been poor, fair, good, excellent?
POOR....................................................................................................... 1
FAIR ......................................................................................................... 2
GOOD ...................................................................................................... 3
EXCELLENT ............................................................................................ 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC2900. Are you using the Infant Medical Care Log? This is the booklet that you or your doctor uses to record information
about your child’s doctor visits.
YES .......................................................................................................... 1 (BOX TC01)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (BOX TC01)
DON’T KNOW .................................................................................... 9--98 (BOX TC01)
TC3000 Is that because…
You haven’t had a medical visit since our last visit with you,.................... 1
You’ve misplaced the log, or .................................................................... 2
You’ve forgotten to bring it to your medical visits? ................................... 3
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX TC01
CHECK ITEM:
IF RESPONDENT LOST THE INFANT MEDICAL CARE LOG TC3000 = “2”
CONTINUE WITH TC3100.
IF RESPONDENT REFUSED INFANT MEDICAL CARE PROVIDER LOG, GO
TO TC3300.
IF RESPONDENT NOT USING INFANT MEDICAL CARE LOG FOR ANY
REASON OTHER THAN LOSS OR NO MEDICAL VISITS TC3000 IN
(“3”,”6”,”7”,”8”), GO TO TC3200.
OTHERWISE, GO TO TC3300.
TC3100. We’ll get another Infant Medical Care Log in the mail to you today.
TC3200. This information is very important to the study. Please keep the log in a safe place and bring the log with you to all
of your child’s medical visits.
Appendix A
A.1.4.c–4
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC3300. I am now going to ask some questions about your child’s visits to a doctor or other health care provider.
Please include routine well visits, sick visits, and any other visits to a doctor or other health care provider at a
clinic, doctor’s office or HMO, emergency room, or hospital outpatient department.
Please refer to the Infant Medical Care Log that you received as part of this study or to any other personal record
or calendar that you keep that would help you to remember the dates of these visits. I’ll be asking you to put a
check mark in the box next to each visit once you’ve finished telling me about it.
If you have the medical care log available, please go and get it now.
TC3400. Since {MONTH} has {CHILD} seen a doctor or heath care provider for any reason?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX TC02)
REFUSED .......................................................................................... 9--97 (BOX TC02)
DON’T KNOW .................................................................................... 9--98 (BOX TC02)
BEGIN LOOP TC01
LOOP:
CYCLE THROUGH TC3500–TC5000 FOR EACH VISIT TO A DOCTOR OR
OTHER HEALTH CARE PROVIDER.
TC3500. {Beginning with the most recent visit, please give me the date of the visit/Please give me the date of the next most
recent visit.}
INTERVIEWER INSTRUCTION:
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR.
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC3600. What kind of place did you take your child to—a clinic or health center, doctor’s office or HMO, a hospital
emergency room, a hospital outpatient department, or some other place?
CLINIC OR HEALTH CENTER ................................................................ 1
DOCTOR’S OFFICE OR HMO................................................................. 2
HOSPITAL EMERGENCY ROOM ........................................................... 3
HOSPITAL OUTPATIENT DEPARTMENT .............................................. 4
SOME OTHER PLACE (SPECIFY):_____________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.c–5
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC3700. What was the main reason for the visit?
Routine well visit,...................................................................................... 1
Sick visit, or .............................................................................................. 3
Some other reason? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(TC4600)
(TC4600)
(TC4600)
(TC4600)
TC3800. At this visit, what was your child’s weight?
WEIGHT MEASURED..............................................................................
WEIGHT NOT MEASURED .....................................................................
1
2 (TC4000)
TC3900. (At this visit, what was your child’s weight?)
|___|___|
POUNDS
OR
|___|___|.|__|
KILOGRAMS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC4000. At this visit, what was your child’s length?
LENGTH/HEIGHT MEASURED ...............................................................
LENGTH/HEIGHT NOT MEASURED ......................................................
1
2 (TC4200)
TC4100. (At this visit, what was your child’s length?)
|___|___|.|__|
INCHES
OR
|___|___|.|__|
CENTIMETERS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC4200 At this visit, what was your child’s head circumference?
HEAD CIRCUMFERENCE MEASURED..................................................
HEAD CIRCUMFERENCE NOT MEASURED .........................................
1
2 (TC4400)
Appendix A
A.1.4.c–6
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC4300. (At this visit, what was your child’s head circumference?)
|___|___|.|__|
INCHES
OR
|___|___|.|__|
CENTIMETERS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC4400. Did your child receive any vaccinations at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC4600)
REFUSED .......................................................................................... 9--97 (TC4600)
DON’T KNOW .................................................................................... 9--98 (TC4600)
TC4500. What did {he/she} receive? What was the lot number for the vaccine your child received?
RECEIVED
YES
NO
Hepatitis B ................................................................................................
Diphtheria, Tetanus, and Pertussis (DTaP) ..............................................
H. Influenza Type B (Hib) .........................................................................
Inactivated Polio (IPV) ..............................................................................
Pneumococcal Conjugate (PCV7)............................................................
Measles, Mumps, and Rubella (German measles)...................................
Varicella (Chickenpox) .............................................................................
Hepatitis A ................................................................................................
Influenza...................................................................................................
Rotavirus ..................................................................................................
Meningococcal .........................................................................................
Other (SPECIFY):___________________________________________
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
TC4600. Did a doctor or other health care provider give your child a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC4800)
REFUSED .......................................................................................... 9--97 (TC4800)
DON’T KNOW .................................................................................... 9--98 (TC4800)
LOT NUMBER
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Appendix A
A.1.4.c–7
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC4700. What was the diagnosis?
INTERVIEWER INSTRUCTION:
ENTER ALL DIAGNOSES IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
DIAGNOSES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC4800. Did your child receive any treatments at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC5000)
REFUSED .......................................................................................... 9--97 (TC5000)
DON’T KNOW .................................................................................... 9--98 (TC5000)
TC4900. What treatments did {he/she} receive?
INTERVIEWER INSTRUCTION:
ENTER ALL TREATMENTS IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC5000. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Infant Medical
Care Log. Has your child had any other visits to a doctor or other health care provider since {MONTH}? Please
include routine well visits, as well as visits to a doctor or other health care provider either at a clinic, doctor’s office
or HMO, emergency room, or outpatient department for any other reason.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_TC01)
REFUSED .......................................................................................... 9--97 (EL_TC01)
DON’T KNOW .................................................................................... 9--98 (EL_TC01)
END LOOP TC01
LOOP:
IF TC5000 = “1,” CYCLE AGAIN.
OTHERWISE, END LOOP AND CONTINUE WITH TC5100.
Appendix A
A.1.4.c–8
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC5100. Since {MONTH} has your child spent at least one night in the hospital?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC5900)
REFUSED .......................................................................................... 9--97 (TC5900)
DON’T KNOW .................................................................................... 9--98 (TC5900)
BEGIN LOOP TC02
LOOP:
CYCLE THROUGH TC5200–TC5800 FOR EACH HOSPITALIZATION.
TC5200. What was the admission date of your child’s {next} most recent hospitalization?
INTERVIEWER INSTRUCTION:
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR.
|___|___| |___|___| |___|___|___|___|
MM
DD
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC5300. How many nights did your child stay at the hospital during this hospitalization?
|___|___|___|
NUMBER OF NIGHTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC5400. Did a doctor or other health care provider give your child a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC5600)
REFUSED .......................................................................................... 9--97 (TC5600)
DON’T KNOW .................................................................................... 9--98 (TC5600)
TC5500. What was the diagnosis?
INTERVIEWER INSTRUCTION:
ENTER ALL DIAGNOSES IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
DIAGNOSES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.c–9
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC5600. Did your child receive any treatments? Please include any vaccinations your child may have received.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (TC5800)
REFUSED .......................................................................................... 9--97 (TC5800)
DON’T KNOW .................................................................................... 9--98 (TC5800)
TC5700. What treatments did your child receive?
INTERVIEWER INSTRUCTION:
ENTER ALL TREATMENTS IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
TC5800. If you haven’t yet, put a check mark in the box next to the visit that you just told me about in your Infant Medical
Care Log. Has your child had any other hospitalizations since {MONTH}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP TC02
LOOP:
IF TC5800 = “1,” CYCLE AGAIN.
OTHERWISE, CONTINUE TC5900.
BOX TC02
CHECK ITEM:
IF 3 MONTH, CONTINUE.
IF 9 MONTH, GO TO BOX TC06.
BOX TC06
CHECK ITEM:
IF 3 MONTH, GO TO TC8760.
IF 9 MONTH, CONTINUE WITH 8400.
Appendix A
A.1.4.c–10
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC8400. Now I’m going to change the subject and ask you about your relationship with your spouse or partner.
Most people have disagreements in their relationships. Please tell me the approximate extent of agreement or
disagreement between you and your spouse or partner for each item.
TC8410. DOES RESPONDENT VOLUNTEER “I DON’T HAVE A SPOUSE/PARTNER”?
R DOES NOT SAY ANYTHING ABOUT HAVING A
SPOUSE/PARTNER ................................................................................
R VOLUNTEERS SHE DOES NOT HAVE A SPOUSE/PARTNER .........
1
2 (EOS)
TC8420. Handling family matters. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8430. Matters of recreation. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8440. Religious matters. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.c–11
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC8450. Demonstrations of affection. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8460. Friends. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8470. Sex relations. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8480. Conventionality or correct or proper behavior. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8490. Philosophy of life. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, .................................................................................... 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.c–12
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC8500. Ways of dealing with parents or in-laws. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8510 Aims, goals, and things believed important. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8520. Amount of time spent together. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8530. Making major decisions. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8540. Household tasks. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.c–13
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC8550. Leisure time interests and activities Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8560. Career decisions. Do you and your spouse or partner:
Always agree,........................................................................................... 1
Almost always agree, ............................................................................... 2
Sometimes agree, .................................................................................... 3
Hardly ever agree, or................................................................................ 4
Never agree?............................................................................................ 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8570. How often do you discuss or have you considered divorce, separation, or terminating your relationship?
All the time,............................................................................................... 1
Most of the time,....................................................................................... 2
Sometimes, .............................................................................................. 3
Hardly ever, or.......................................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8580. How often do you or your mate leave the house after a fight?
All the time,............................................................................................... 1
Most of the time,....................................................................................... 2
Sometimes, .............................................................................................. 3
Hardly ever, or.......................................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8590. In general, how often do you think that things between you and your partner are going well?
All the time,............................................................................................... 1
Most of the time,....................................................................................... 2
Sometimes, .............................................................................................. 3
Hardly ever, or.......................................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.c–14
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC8600. How often do you confide in your partner?
All the time,............................................................................................... 1
Most of the time,....................................................................................... 2
Sometimes, .............................................................................................. 3
Hardly ever, or.......................................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8610. How often do you regret that you married your partner (or lived together)?
All the time,............................................................................................... 1
Most of the time,....................................................................................... 2
Sometimes, .............................................................................................. 3
Hardly ever, or.......................................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8620. How often do you and your partner quarrel?
All the time,............................................................................................... 1
Most of the time,....................................................................................... 2
Sometimes, .............................................................................................. 3
Hardly ever, or.......................................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8630. How often do you and your partner “get on each other’s nerves”?
All the time,............................................................................................... 1
Most of the time,....................................................................................... 2
Sometimes, .............................................................................................. 3
Hardly ever, or.......................................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8640. How often do you kiss your partner?
Every day, ................................................................................................ 1
Almost every day, ..................................................................................... 2
Sometimes, .............................................................................................. 3
Hardly ever, or.......................................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.c–15
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC8650. How often do you and your partner engage in outside interests together?
Every day, ................................................................................................ 1
Almost every day, ..................................................................................... 2
Sometimes, .............................................................................................. 3
Hardly ever, or.......................................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8660. Please tell me how often you do the following with your spouse or partner.
TC8670. How often do you have an interesting chat:
Never,....................................................................................................... 1
Less than once a month, .......................................................................... 2
Once or twice a month, ............................................................................ 3
Once or twice a week, .............................................................................. 4
Once a day, or.......................................................................................... 5
More often? .............................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8680. How often do you laugh together:
Never,....................................................................................................... 1
Less than once a month, .......................................................................... 2
Once or twice a month, ............................................................................ 3
Once or twice a week, .............................................................................. 4
Once a day, or.......................................................................................... 5
More often? .............................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8690. How often do you calmly discuss something:
Never,....................................................................................................... 1
Less than once a month, .......................................................................... 2
Once or twice a month, ............................................................................ 3
Once or twice a week, .............................................................................. 4
Once a day, .............................................................................................. 5
More often? .............................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.c–16
Version 1/20/08
Visit: 3 Month, 9 Month
Target: Mother
TC8700. How often do you work together on a project:
Never,....................................................................................................... 1
Less than once a month, .......................................................................... 2
Once or twice a month, ............................................................................ 3
Once or twice a week, .............................................................................. 4
Once a day, .............................................................................................. 5
More often? .............................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8710. Please tell me if the following items were problems in your relationship during the past few weeks.
TC8720 Being too tired for sex.
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8730. Not showing love.
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8740. Please indicate the degree of happiness in your relationship. Are you:
Very unhappy, ........................................................................................ 1
Somewhat unhappy,................................................................................. 2
Fairly happy, ............................................................................................ 3
Mostly happy, or ....................................................................................... 4
Very happy? ............................................................................................. 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
TC8750. Which of the following statements best describes how you feel about the future of your relationship?
I want desperately for my relationship to succeed, and would go to
almost any length to see that it does ..................................................... 1
I want very much for my relationship to succeed, and will do all I can
to see that it does .................................................................................. 2
I want very much for my relationship to succeed, and will do my fair
share to see that it does ........................................................................ 3
It would be nice if my relationship succeeded, but I can’t do much
more than I’m doing now to help it succeed .......................................... 4
My relationship can never succeed, and there is no more that I can
do to keep the relationship going........................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
Version 1/20/08
A.1.4.c–17
Visit: 3 Month, 9 Month
Target: Mother
TC8760 These are all the questions I have at this time. {We’ll send another Infant Medical Care Log in the mail, right
away.} Please remember to take the medical care log with you to your child’s doctor visits. Thank you for your
time.
Appendix A
A.1.4.d–1
Version 1/20/08
Visit Type: 12 Month
Target: Female
12-Month Visit: Introduction
IN0100. We are about to begin the interview portion of today’s home visit, which will take about 45 minutes to complete.
Your answers are important to us. There are no right or wrong answers, just those that help us to understand your
situation. There are questions about your child, where you live, your lifestyle routines, and your feelings during
this interview and you can always refuse to answer any question or group of questions. If you need a bathroom
break at any time please let me know so that I can give you the materials to collect the samples that are needed
today.
Before we start, can you get the medicines, any pesticide products, and the Infant Medical Care Log that you
were asked to gather for this appointment?
IN0200. AFTER RESPONDENT GATHERS MATERIALS, OR INDICATES THAT SHE DOESN’T HAVE ANY TO
GATHER, SAY:
Are you ready to begin?
YES ..........................................................................................................
NO ............................................................................................................
1
2 (END INTERVIEW)
Appendix A
A.1.4.d–2
Version 1/20/08
Visit Type: 12 Month
Target: Mother
12-Month Visit: Child Medical History
CM1500.Now I’d like to change the subject and ask about your child’s health and development. You may notice your
baby’s personality developing a bit more now that he or she is 12 months old. Overall would you describe your
baby as:
YES
NO
RF
DK
a.
b.
c.
d.
e.
f.
g.
Calm?...................................................................................................
Worried? ..............................................................................................
Sociable or outgoing? ..........................................................................
Angry?..................................................................................................
Shy or quiet? ........................................................................................
Stubborn? ............................................................................................
Happy?.................................................................................................
1
1
1
1
1
1
1
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
CM1600.Since {MONTH}, would you say {CHILD’s} health has been poor, fair, good, excellent?
POOR....................................................................................................... 1
FAIR ......................................................................................................... 2
GOOD ...................................................................................................... 3
EXCELLENT ............................................................................................ 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM1700.I will read you a list of things your baby may already do or may start doing when {he/she} gets older. Does your
baby…
YES
NO
RF
DK
Follow you with {his/her} eyes? ................................................................
Smile when you smile at him/her?............................................................
Try to get a toy that is out of reach? .........................................................
Feed {him/herself} a cracker or cereal?....................................................
Wave goodbye? .......................................................................................
Reaches for toys or food held to him/her?................................................
Grab an object like a block or rattle from you? .........................................
Move a toy or block from one hand to the other? .....................................
Pick up a small object like a Cheerio or raisin? ........................................
Hold two toys or blocks at a time, one in each hand? ..............................
Startle or react to a sound? ......................................................................
Turns towards a sound? ...........................................................................
Turns toward someone when they’re speaking? ......................................
Makes sounds as though he/she is trying to speak? ................................
Says “mama” or “dada”?...........................................................................
Can keep head steady when sitting or held up?.......................................
Rolls over from stomach to back? ............................................................
Rolls from back to stomach? ....................................................................
Sit up by {him/herself}? ............................................................................
Stand while holding onto something? .......................................................
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
Appendix A
A.1.4.d–3
Version 1/20/08
Visit Type: 12 Month
Target: Mother
CM1800.Since {MONTH} has {CHILD} had a runny nose, cough, or cold?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CM2000)
REFUSED .......................................................................................... 9--97 (CM2000)
DON’T KNOW .................................................................................... 9--98 (CM2000)
CM2000.Since {MONTH} has {CHILD} had an ear infection?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CM2200)
REFUSED .......................................................................................... 9--97 (CM2200)
DON’T KNOW .................................................................................... 9--98 (CM2200)
CM2200.Since {MONTH} has {CHILD} had diarrhea or vomiting?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CM2400)
REFUSED .......................................................................................... 9--97 (CM2400)
DON’T KNOW .................................................................................... 9--98 (CM2400)
CM2400.Since {MONTH} has {CHILD} had wheezing or whistling in the chest?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CM2600)
REFUSED .......................................................................................... 9--97 (CM2600)
DON’T KNOW .................................................................................... 9--98 (CM2600)
CM2600.Since {MONTH}, on how many days has {CHILD} had a fever over 101 degrees, not related to receiving
immunizations? (IF NEEDED: or 38.3 degrees Celsius?)
|___|___|___|
NUMBER OF DAYS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CM2700.Now I have some questions about specific conditions or health problems {CHILD} may have.
CM2800.Since {MONTH}, has a doctor told you that {CHILD} is blind?
YES .......................................................................................................... 1 (CM3000)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–4
Version 1/20/08
Visit Type: 12 Month
Target: Mother
CM2900.Since {MONTH}, has a doctor told you that {CHILD} has difficulty seeing, including nearsightedness and
farsightedness?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM3000.Since {MONTH}, has a doctor told you that {CHILD} has difficulty hearing or deafness? Do not include a
temporary loss of hearing due to a cold or congestion.
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM3100.Since {MONTH}, has a doctor told you that {CHILD} has any congenital anomaly or birth defect such as a cleft lip
or palate, heart defect, or spina bifida?
YES (SPECIFY) ____________________________________________ 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM3200.Since {MONTH}, has a doctor told you that {CHILD} has failure to thrive or concern about proper growth?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM3300.Since {MONTH}, has a doctor told you that {CHILD} has a problem with using {his/her} arms or hands?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM3400.Since {MONTH}, has a doctor told you that {CHILD} has Down Syndrome, Turner Syndrome, or another inherited
or genetic condition?
YES (SPECIFY): ___________________________________________ 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–5
Version 1/20/08
Visit Type: 12 Month
Target: Mother
CM3500.Since {MONTH}, has a doctor told you that {CHILD} has any other types of special needs or limitations?
YES (SPECIFY): ___________________________________________ 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX CM01
CHECK ITEM:
IF ANY CM2800–CM3500 = “1” AT CURRENT OR ANY PREVIOUS INTERVIEW,
CONTINUE WITH CM3600.
OTHERWISE GO TO CM3900.
CM3600.Next, I’m going to read a list of services. For each service, please tell me if {CHILD} or your family received this
service to help with {CHILD}’s special needs.
YES
NO
RF
DK
a.
b.
c.
d.
e.
f.
g.
Physical therapy?.................................................................................
Vision services? ...................................................................................
Hearing services? ................................................................................
Social work services?...........................................................................
Psychological services? .......................................................................
Home visits? ........................................................................................
Parent support or training?...................................................................
1
1
1
1
1
1
1
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
CM3700.Is {CHILD} currently participating in an early intervention program or regularly receiving any services for {his/her}
condition{s} from:
YES
NO
RF
DK
a.
b.
c.
d.
e.
f.
Your local school district? ....................................................................
A state or local health agency? ............................................................
A social service agency?......................................................................
A private doctor’s office?......................................................................
A clinic?................................................................................................
Some other source?.............................................................................
1
1
1
1
1
1
ROUTING INSTRUCTION: IF CM3700f = “1” CONTINUE. OTHERWISE, GO TO CM3900.
CM3800.What is that other source?
_______________________________
OTHER SOURCE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
Appendix A
A.1.4.d–6
Version 1/20/08
Visit Type: 12 Month
Target: Mother
CM3900.The next questions are about the health insurance plans for {CHILD}. For this kind of insurance, people often pay
part of the premium and they may obtain it through work, purchase it directly, or receive it through a state or local
government program or community program.
CM4000.Is {CHILD} covered by any kind of health insurance or some other kind of health care plan?
PROBE: Include health insurance obtained through employment or purchased directly, as well as government
programs like Medicaid and CHIP that provide medical care or help pay bills?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
CM4100 What kind of health insurance or health care coverage does {CHILD} have? Does {he/she} have coverage
through a private health insurance plan (from employer, workplace, or purchased directly, or through a state or
local government program or community program)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM4200.(Does {he/she} have coverage through)
Medicaid {or name of state program}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM4300.(Does {he/she} have coverage through)
CHIP (Children’s Health Insurance Program) {or name of state program}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM4400.(Does {he/she} have coverage through)
Military health care/TRICARE/CHAMPUS/CHAMP-VA?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–7
Version 1/20/08
Visit Type: 12 Month
Target: Mother
CM4500.(Does {he/she} have coverage through)
Indian Health Service?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
CM4600.(Does {he/she} have coverage through)
Another government program (Medicare {, {State-sponsored health plan}})?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–8
Version 1/20/08
Visit Type: 12 Month
Target: Mother
12-Month Visit: Health Behaviors
HB0400. The next questions are about your child’s exposure to environmental tobacco smoke.
HB0500. Do you currently smoke cigarettes or use any other tobacco product?
YES ......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB0600. {Including yourself, how/How} many smokers live in your home now?
|___|___|
NUMBER OF SMOKERS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
HB0700. {Do you/Does anyone} smoke inside the house?
YES ......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB0800. Which of the following statements describes the rules about smoking inside your home now?
No one is allowed to smoke anywhere inside my home, .......................... 1
Smoking is allowed in some rooms at some times, or.............................. 2
Smoking is permitted anywhere inside my home ..................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HB0900.On average, about how many hours per day do people smoke in the same room as {CHILD}, or near enough
that {he/she} can see or smell the smoke? Please consider all the places {CHILD} is during the day, including at
home, at daycare, or some other place. If {he/she} is not exposed to smoke, enter “0.”
|___|___|
HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.d–9
Version 1/20/08
Visit Type: 12 Month
Target: Mother
HB1000.Do you drink any type of alcoholic beverage?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
HB1100. How often do you have 5 or more drinks within a couple of hours:
Never,....................................................................................................... 1
About once a month, ................................................................................ 2
About once a week, or.............................................................................. 3
About once a day? ................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–10
Version 1/20/08
Visit Type: 12 Month
Target: Mother
12-Month Visit: Parenting Practices and Beliefs
PB0100. These next questions are about different things you may do as a parent. How often do you feel the following ways
or do the following things?
PB0200. How often do you talk a lot about your child to friends and family?
SHOW CARD PB1.
All of the time,........................................................................................... 1
Some of the time, ..................................................................................... 2
Rarely, or ................................................................................................. 3
Never?...................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB0300. How often do you carry pictures of your child with you wherever you go?
SHOW CARD PB1.
ALL OF THE TIME ................................................................................... 1
SOME OF THE TIME ............................................................................... 2
RARELY ................................................................................................... 3
NEVER ..................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB0400. How often do you find yourself thinking about your child?
SHOW CARD PB1.
ALL OF THE TIME ................................................................................... 1
SOME OF THE TIME ............................................................................... 2
RARELY ................................................................................................... 3
NEVER ..................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB0500. How often do you think holding and cuddling your child is fun?
SHOW CARD PB1.
ALL OF THE TIME ................................................................................... 1
SOME OF THE TIME ............................................................................... 2
RARELY ................................................................................................... 3
NEVER ..................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–11
Version 1/20/08
Visit Type: 12 Month
Target: Mother
PB0600. How often do you think it’s more fun to get your child something new than to get yourself something new?
SHOW CARD PB1.
ALL OF THE TIME ................................................................................... 1
SOME OF THE TIME ............................................................................... 2
RARELY ................................................................................................... 3
NEVER ..................................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB0700. How strongly do you agree or disagree with the following statement. Babies have to learn they can’t be picked up
every time they cry.
Strongly agree, ......................................................................................... 1
Agree,....................................................................................................... 2
Neither agree nor disagree,...................................................................... 3
Disagree, or.............................................................................................. 4
Strongly disagree? ................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB0800. Do you read to or look at books with your child?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PB1000)
REFUSED .......................................................................................... 9--97 (PB1000)
DON’T KNOW .................................................................................... 9--98 (PB1000)
PB0900. How often do you read or look at books with your child?
Every day, ................................................................................................ 1
5–6 days a week, ..................................................................................... 2
2–4 days a week, or ................................................................................. 3
Once a week or less? ............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1000. When you are reading to or looking at books with your child, do you try to teach your child:
No, he/she is too young,........................................................................... 1
No, I do not have time, ............................................................................. 2
Yes, occasionally, or ................................................................................ 3
Yes, often? ............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–12
Version 1/20/08
Visit Type: 12 Month
Target: Mother
PB1100. Does your child watch TV and/or DVDs?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (PB1800)
REFUSED .......................................................................................... 9--97 (PB1800)
DON’T KNOW .................................................................................... 9--98 (PB1800)
PB1200. How often does your child watch TV and/or DVDs?
Every day, ................................................................................................ 1
5–6 days a week, ..................................................................................... 2
2–4 days a week, or ................................................................................. 3
Once a week or less? ............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1300. How often does your child watch TV and/or DVDs for entertainment?
Every day, ................................................................................................ 1
5–6 days a week, ..................................................................................... 2
2–4 days a week, or ................................................................................. 3
Once a week or less? ............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1400. How often does your child watch TV and/or DVDs for education?
Every day, ................................................................................................ 1
5–6 days a week, ..................................................................................... 2
2–4 days a week, or ................................................................................. 3
Once a week or less? ............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1500. How often does your child watch TV and/or DVDs to relax or calm them?
Every day, ................................................................................................ 1
5–6 days a week, ..................................................................................... 2
2–4 days a week, or ................................................................................. 3
Once a week or less? ............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–13
Version 1/20/08
Visit Type: 12 Month
Target: Mother
PB1600. How often does your child watch TV and/or DVDs to keep them occupied while you get other things done?
Every day, ................................................................................................ 1
5–6 days a week, ..................................................................................... 2
2–4 days a week, or ................................................................................. 3
Once a week or less? ............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1700. When you are watching TV or DVDs with your child, do you try to teach your child?
No, he/she is too young,........................................................................... 1
No, I do not have time, ............................................................................. 2
Yes, occasionally, or ................................................................................ 3
Yes, often ................................................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1800. How often do you play with toys with your baby?
Every day, ................................................................................................ 1
5–6 days a week, ..................................................................................... 2
2-4 days a week, or .................................................................................. 3
Once a week or less? ............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1600. How often do you go for walks with your baby?
Every day, ................................................................................................ 1
5-6 days a week, ...................................................................................... 2
2–4 days a week, or ................................................................................. 3
Once a week or less? ............................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1700. This next few questions asks about how you think most young children act, how they grow, and how to care for
them.
Please answer each of the following questions based on young children in general, not about your child and how
he or she acts. Think about what you know about young children you have had contact with or anything you have
read.
For each of the following statements, say whether, for most young children, you agree or disagree with the
statement, or are not sure.
Appendix A
A.1.4.d–14
Version 1/20/08
Visit Type: 12 Month
Target: Mother
PB1800. All infants need the same amount of sleep.
SHOW CARD PB2.
AGREE..................................................................................................... 1
DISAGREE............................................................................................... 2
NOT SURE............................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB1900. A young brother or sister may start wetting the bed or thumbsucking when a new baby arrives in the family.
SHOW CARD PB2.
AGREE..................................................................................................... 1
DISAGREE............................................................................................... 2
NOT SURE............................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB2000. A child thinks he or she is speaking correctly even when he or she says words and sentences in an unusual or
different way, like “I goed to town” or “What the dollie have?”
SHOW CARD PB2.
AGREE..................................................................................................... 1
DISAGREE............................................................................................... 2
NOT SURE............................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB2100. Children learn all of their language by copying what they have heard adults say.
SHOW CARD PB2.
AGREE..................................................................................................... 1
DISAGREE............................................................................................... 2
NOT SURE............................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–15
Version 1/20/08
Visit Type: 12 Month
Target: Mother
PB2200. The next statements are about the age at which young children can first do something. If you think the age is
about right, say you agree. If you don’t agree, please say whether you think a child is younger or older when they
can first do these things. If you aren’t sure, then state that you are not sure.
PB2300. A 1-year-old knows right from wrong.
SHOW CARD PB3.
AGREE..................................................................................................... 1
OLDER ..................................................................................................... 2
YOUNGER ............................................................................................... 3
NOT SURE............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB2400. A baby will begin to respond to her name at 10 months.
SHOW CARD PB3.
AGREE..................................................................................................... 1
OLDER ..................................................................................................... 2
YOUNGER ............................................................................................... 3
NOT SURE............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB2500. Most infants are ready to be toilet trained by 1 year of age.
SHOW CARD PB3.
AGREE..................................................................................................... 1
OLDER ..................................................................................................... 2
YOUNGER ............................................................................................... 3
NOT SURE............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB2600. A baby of 12 months can remember toys he has watched being hidden.
SHOW CARD PB3.
AGREE..................................................................................................... 1
OLDER ..................................................................................................... 2
YOUNGER ............................................................................................... 3
NOT SURE............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–16
Version 1/20/08
Visit Type: 12 Month
Target: Mother
PB2700. One-year-olds often cooperate and share when they play together.
SHOW CARD PB3.
AGREE..................................................................................................... 1
OLDER ..................................................................................................... 2
YOUNGER ............................................................................................... 3
NOT SURE............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB2800. A baby is about 7 months old before she can reach for and grab things.
SHOW CARD PB3.
AGREE..................................................................................................... 1
OLDER ..................................................................................................... 2
YOUNGER ............................................................................................... 3
NOT SURE............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PB2900. A baby usually says his first real word by 6 moths of age.
SHOW CARD PB3.
AGREE..................................................................................................... 1
OLDER ..................................................................................................... 2
YOUNGER ............................................................................................... 3
NOT SURE............................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d –17
Version 1/20/08
Visit Type: 12 Month
Target: Mother
12-Month Visit: Child Care Arrangements
Next, I’d like to ask you about different types of child care {CHILD} may receive from someone other than parents or
guardians. This includes regularly scheduled care arrangements with relatives and non-relatives, and day care or early
childhood programs, whether or not there is a charge or fee, but not occasional babysitting.
Section A: Any Regularly Scheduled Non-Parental Child Care
A01.
Does {CHILD} currently receive any regularly scheduled care from someone other than a parent or guardian, for
example from relatives, non-relatives, or a child care center or program?
Yes ........................................................................................................... 1
No............................................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX A02
CHECK ITEM:
IF CHILD IS CURRENTLY RECEIVING REGULAR NON-PARENTAL CARE (A01
= 1), GO TO SECTION B.
ELSE, END CHILD CARE ARRANGEMENTS SECTION.
Section B. Care by a Relative Other Than a Parent or Guardian
B01.
I’d like you to think about all the care {CHILD} receives from relatives, for example, from grandparents, brothers or
sisters, or any other relatives. This includes all regularly scheduled care arrangements with relatives that happen
at least weekly, but does not include occasional babysitting. Including all of these regular arrangements, how
many total hours each week does {CHILD} receive care from relatives?
|___|___|
NUMBER OF HOURS PER WEEK
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX B02
CHECK ITEM:
IF CHILD IS CURRENTLY RECEIVING CARE FROM RELATIVES FOR 10 OR
MORE HOURS PER WEEK (B01 > 10) GO TO B04.
ELSE, GO TO SECTION C.
Appendix A
A.1.4.d–18
Version 1/20/08
B04.
Visit Type: 12 Month
Target: Mother
How many care arrangements with relatives does {CHILD} have that are regularly scheduled for 10 hours or more
each week?
|___|___|
NUMBER OF CARE ARRANGEMENTS AT 10 HOURS OR MORE
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX B05
CHECK ITEM:
IF CHILD HAS ONE OR MORE RELATIVE CARE ARRANGEMENTS THAT
LAST FOR 10 OR MORE HOURS PER WEEK (B04 > 1), GO TO BOX B06.
ELSE, GO TO SECTION C.
BOX B06
CHECK ITEM:
ASK B07 THROUGH B31 FOR EACH RELATIVE WHO PROVIDES 10 OR
MORE HOURS PER WEEK OF CARE FOR CHILD
B07.
[Let’s start with the relative who provides the most care for {CHILD} now./Now let’s talk about the next relative
who cares for {CHILD}]. How is this person related to {CHILD}?
Grandmother ............................................................................................ 1
Grandfather .............................................................................................. 2
Aunt .......................................................................................................... 3
Uncle ........................................................................................................ 4
Brother...................................................................................................... 5
Sister ........................................................................................................ 6
Another Relative (SPECIFY): __________________________________ 7
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
B10.
Is the care provided by {{CHILD}’s {RELATIVE}/that relative} in your home or in another home?
Own home ................................................................................................ 1
Other home .............................................................................................. 2
Both/Varies............................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–19
Version 1/20/08
B13.
Visit Type: 12 Month
Target: Mother
Does {{CHILD}’s {RELATIVE}/that relative} who provides this care live in your household? PROBE: Include
persons living in in-law suites, above garages, or in quarters attached to house.
Yes ........................................................................................................... 1
No............................................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
B16.
How many hours each week does {CHILD} receive care from {{his/her}{RELATIVE}/that relative}?
|___|___|
NUMBER OF HOURS PER WEEK
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
B19.
9--97
9--98
How old was {CHILD} in months when this particular regular care arrangement with {{his/her} {RELATIVE}/that
relative} began?
|___|___|
AGE IN MONTHS WHEN CARE WITH RELATIVE BEGAN
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
B22.
9--97
9--98
How many children are usually cared for together, in the same group at the same time, by {{CHILD}’s
{RELATIVE}/that relative}, counting {CHILD}?
|___|___|
NUMBER OF CHILDREN
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
B25.
9--97
9--98
How many adults usually care for {CHILD} at the same time during that care arrangement?
|___|___|
NUMBER OF ADULTS
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.d–20
Version 1/20/08
B28.
Visit Type: 12 Month
Target: Mother
Does the child care provider allow you or other parents to leave children who are sick?
No, the parent/s have to make other arrangements if the child
is at all sick (e.g., a cold or sniffles but no fever, or fever under
some predetermined level, such as 100)............................................... 1
No, the parent/s have to make other arrangements if the child is
very sick (e.g., any fever over some predetermined level, such
as 100.1) ............................................................................................... 2
Yes, the parent/s can leave the child as usual ......................................... 3
Yes, the provider takes the child, but keeps him/her isolated from
other children (or there are no other children) ....................................... 4
Yes, the provider takes the child, and makes other arrangements
for the child (has someone else take care of the child, etc.).................. 5
Other (SPECIFY):___________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX B29
CHECK ITEM:
IF B10 = 2 or B10 = 3, GO TO B31.
ELSE, GO TO B37.
B31.
May I have the address where this relative provides care for your child? [IF NEEDED: We will not use this
information to contact your relative. We will only use this information for analysis.]
_____________________________________________________
STREET NUMBER
STREET NAME
APT #
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
BOX B29
CHECK ITEM:
IF (CITY AND STATE) OR ZIP WAS PROVIDED IN B31, GO TO BOX B35.
ELSE, GO TO B34.
B34.
About how many miles is the {CHILD}’s {RELATIVE/relative caregiver} from your house?
|___|___|
NUMBER OF MILES
Appendix A
A.1.4.d–21
Version 1/20/08
Visit Type: 12 Month
Target: Mother
BOX B35
CHECK ITEM:
IF B04 = 1 (ONE RELATIVE ARRANGEMENT), GO TO B37.
IF B04 > 2 (MORE THAN ONE RELATIVE ARRANGEMENT), RETURN TO B07
UNTIL THE NUMBER OF ARRANGEMENTS IN B04 IS COMPLETED, THEN GO
TO B37.
B37.
Does {CHILD} have another care arrangement with a relative that is regularly scheduled for 10 hours or more per
week?
Yes ........................................................................................................... 1 (GO TO B07)
No............................................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Section C: Care by a Non-Relative
Now I’d like to ask you about any regularly scheduled care {CHILD} receives from someone not related to {him/her}, either
in your home or someone else’s home. This includes all regularly scheduled care arrangements with non-relatives that
happen at least weekly, including home child care providers, regularly scheduled sitter arrangements, or neighbors. This
does not include day care centers, early childhood programs, or occasional babysitting.
C01.
I’d like you to think about all the regularly scheduled care your child receives on a weekly basis from non-relatives
in a home setting. Including all of these arrangements, how many total hours each week does {CHILD} receive
care from non-relatives in a home setting?
|___|___|
NUMBER OF HOURS PER WEEK
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX C02
CHECK ITEM:
IF CHILD IS CURRENTLY RECEIVING CARE FROM NON-RELATIVES FOR 10
OR MORE HOURS PER WEEK (C01 > 10), GO TO C04.
ELSE, GO TO SECTION D.
Appendix A
A.1.4.d–22
Version 1/20/08
C04.
Visit Type: 12 Month
Target: Mother
How many care arrangements with non-relatives does {CHILD} have that are regularly scheduled for 10 hours or
more each week?
|___|___|
NUMBER OF CARE ARRANGEMENTS AT 10 HOURS OR MORE
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX C05
CHECK ITEM:
IF CHILD HAS ONE OR MORE NON-RELATIVE CARE ARRANGEMENTS THAT
LAST FOR 10 OR MORE HOURS PER WEEK (C04 > 1), GO TO BOX C06.
ELSE, GO TO SECTION D.
BOX C06
CHECK ITEM:
ASK C07 THROUGH C28 FOR EACH NON-RELATIVE WHO PROVIDES 10 OR
MORE HOURS PER WEEK OF CARE FOR CHILD
C07.
[Let’s talk about the non-relative who provides the most care for {CHILD} now./Now let’s talk about the next nonrelative who cares for {CHILD}.]
Is that care provided in your home or another home?
Own home ................................................................................................ 1
Other home .............................................................................................. 2
Both/Varies............................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
C10.
Does this person who cares for {CHILD} live in your household? PROBE: Include persons living in in-law suites,
above garages, or in quarters attached to house.
Yes ........................................................................................................... 1
No............................................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–23
Version 1/20/08
C13.
Visit Type: 12 Month
Target: Mother
How many hours each week does {CHILD} receive care from that person?
|___|___|
NUMBER OF HOURS PER WEEK
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
C16.
9--97
9--98
How old was {CHILD} in months when this particular care arrangement began?
|___|___|
AGE IN MONTHS WHEN CARE BEGAN
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
C19.
9--97
9--98
How many children are usually cared for together, in the same group at the same time, by that person, counting
{CHILD}?
|___|___|
NUMBER OF CHILDREN
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
C22.
9--97
9--98
How many adults usually care for {CHILD} at the same time during that care arrangement?
|___|___|
NUMBER OF ADULTS
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.d–24
Version 1/20/08
C25.
Visit Type: 12 Month
Target: Mother
Does the child care provider allow you or other parents to leave children who are sick?
No, the parent/s have to make other arrangements if the child
is at all sick (e.g., a cold or sniffles but no fever, or fever under
some predetermined level, such as 100)............................................... 1
No, the parent/s have to make other arrangements if the child is
very sick (e.g., any fever over some predetermined level, such
as 100.1) ............................................................................................... 2
Yes, the parent/s can leave the child as usual ......................................... 3
Yes, the provider takes the child, but keeps him/her isolated from
other children (or there are no other children) ....................................... 4
Yes, the provider takes the child, and makes other arrangements
for the child (has someone else take care of the child, etc.).................. 5
Other (SPECIFY):___________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX C23
CHECK ITEM:
IF C07 = 2 or C07 = 3, GO TO C28.
ELSE, GO TO C34.
C28.
May I have the address where this person provides care for your child? [IF NEEDED: We will not use this
information to contact your child’s care provider. We will only use this information for analysis.]
_____________________________________________________
STREET NUMBER
STREET NAME
APT #
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
BOX C29
CHECK ITEM:
IF (CITY AND STATE) OR ZIP WAS PROVIDED IN C28, GO TO BOX C32.
ELSE, GO TO C31.
C31.
About how many miles is the {CHILD}’s {RELATIVE/relative caregiver} from your house?
|___|___|
NUMBER OF MILES
Appendix A
A.1.4.d–25
Version 1/20/08
Visit Type: 12 Month
Target: Mother
BOX C32
CHECK ITEM:
IF C04 = 1 (ONE NON-RELATIVE ARRANGEMENT), GO TO C34.
IF C04 > 2 (MORE THAN ONE 10 HOUR NON-RELATIVE ARRANGEMENT),
RETURN TO C07 UNTIL THE NUMBER OF ARRANGEMENTS IN C04 IS
COMPLETED, THEN GO TO C34.
C34.
Does {CHILD} have another care arrangement with a non-relative that is regularly scheduled for 10 hours or more
each week?
Yes ........................................................................................................... 1 (GO TO C07)
No............................................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Section D. Center-Based Care
Now I want to ask you about child care centers {CHILD} may attend on a regular basis. Such centers include day care
centers, early learning centers, nursery schools, and preschools.
D01.
I’d like you to think about all the care your child receives from child care centers. This includes all regularly
scheduled care arrangements in child care centers that happen at least weekly. Including all of these
arrangements, how many total hours each week does {CHILD} receive care at child care centers?
|___|___|
NUMBER OF HOURS PER WEEK
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX D02
CHECK ITEM:
IF CHILD IS CURRENTLY RECEIVING CENTER-BASED CARE FOR 10 OR
MORE HOURS PER WEEK, GO TO D04.
ELSE, END CHILD CARE INTERVIEW.
D04.
How many different child care center arrangements does {CHILD} have, where {CHILD} goes for at least 10 hours
each week?
|___|___|
NUMBER OF CARE ARRANGEMENTS AT 10 HOURS OR MORE
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.d–26
Version 1/20/08
Visit Type: 12 Month
Target: Mother
BOX D05
CHECK ITEM:
IF CHILD HAS ONE OR MORE CENTER-BASED CARE ARRANGEMENT THAT
LASTS FOR 10 OR MORE HOURS PER WEEK (D04 > 1), GO TO BOX D06.
ELSE, END CHILD CARE INTERVIEW.
BOX D06
CHECK ITEM:
ASK D07 THROUGH D22 FOR EACH CHILD CARE CENTER WHERE THE
CHILD SPENDS 10 OR MORE HOURS PER WEEK.
D07.
[Let’s talk about the program where {CHILD} spends most of his/her time./Now let’s talk about the next program
that {CHILD} currently goes to.] How many hours each week does {CHILD} go to that program?
|___|___|
NUMBER OF HOURS PER WEEK
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
D10.
9--97
9--98
How old was {CHILD} in months when {he/she} started going to this particular program?
|___|___|
AGE IN MONTHS WHEN CARE BEGAN
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
D13.
9--97
9--98
How many children are usually in {CHILD}’s room or group, at the same time, at that program, counting {CHILD}?
|___|___|
NUMBER OF CHILDREN
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.d–27
Version 1/20/08
D16.
Visit Type: 12 Month
Target: Mother
How many adults are usually in {CHILD}’s room or group, at the same time, at that program?
|___|___|
NUMBER OF ADULTS
OR
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
D19.
9--97
9--98
Does the child care provider allow you or other parents to leave children who are sick?
No, the parent/s have to make other arrangements if the child
is at all sick (e.g., a cold or sniffles but no fever, or fever under
some predetermined level, such as 100)............................................... 1
No, the parent/s have to make other arrangements if the child is
very sick (e.g., any fever over some predetermined level, such
as 100.1) ............................................................................................... 2
Yes, the parent/s can leave the child as usual ......................................... 3
Yes, the provider takes the child, but keeps him/her isolated from
other children (or there are no other children) ....................................... 4
Yes, the provider takes the child, and makes other arrangements
for the child (has someone else take care of the child, etc.).................. 5
Other (SPECIFY):___________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
D22.
May I have the address of this child care program? [IF NEEDED: We will not use this information to contact your
child’s care provider. We will only use this information for analysis.]
_____________________________________________________
STREET NUMBER
STREET NAME
APT #
_____________________________________________________
CITY
|___|___|
STATE
|___|___|___|___|___|
ZIP CODE
BOX D23
CHECK ITEM:
IF (CITY AND STATE) OR ZIP WAS PROVIDED IN D22, GO TO BOX D26.
ELSE, GO TO D25.
D25.
About how many miles is the {CHILD}’s {RELATIVE/relative caregiver} from your house?
|___|___|
NUMBER OF MILES
Appendix A
A.1.4.d–28
Version 1/20/08
Visit Type: 12 Month
Target: Mother
BOX D26
CHECK ITEM:
IF D04 = 1 (ONE 10 HOUR CENTER-BASED ARRANGEMENT), GO TO D28.
IF D04 > 2 (MORE THAN ONE 10 HOUR CENTER-BASED ARRANGEMENT),
RETURN TO D07 UNTIL THE NUMBER OF ARRANGEMENTS IN D04 IS
COMPLETED, THEN GO TO D28.
D28.
Does {CHILD} go to another child care center for at least 10 hours a week?
Yes ........................................................................................................... 1 (GO TO D07)
No............................................................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–29
Version 1/20/08
Visit Type: 12 Month
Target: Female
12-Month Visit: Doctor Visits and Hospitalizations
CV0100. I am now going to ask some questions about your child’s visits to a doctor or other health care provider. Please
include routine well visits, sick visits, and any other visits to a doctor or other health care provider at a clinic,
doctor’s office or HMO, emergency room, or hospital outpatient department. Please refer to the Infant Medical
Care Log that you received as part of this study or to any other personal record or calendar that you keep that
would help you to remember the dates of these visits. I’ll be asking you to put a check mark in the box next to
each visit once you’ve finished telling me about it. If you have this information available, please go and get it now.
CV0200.Since {MONTH} has {CHILD} seen a doctor or heath care provider for any reason?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
BEGIN LOOP CV01
LOOP:
CYCLE THROUGH CV0300–CV1600 FOR EACH VISIT TO A DOCTOR OR
OTHER HEALTH CARE PROVIDER.
CV0300. {Beginning with the most recent visit, please give me the date of the visit/Please give me the date of the next most
recent visit.}
INTERVIEWER INSTRUCTION:
ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR.
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV0400. What kind of place did you take your child to—a clinic or health center, doctor’s office or HMO, a hospital
emergency room, a hospital outpatient department, or some other place?
CLINIC OR HEALTH CENTER ................................................................ 1
DOCTOR’S OFFICE OR HMO................................................................. 2
HOSPITAL EMERGENCY ROOM ........................................................... 3
HOSPITAL OUTPATIENT DEPARTMENT .............................................. 4
SOME OTHER PLACE (SPECIFY):_____________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–30
Version 1/20/08
Visit Type: 12 Month
Target: Female
CV0500. What was the main reason for the visit?
Routine well visit,...................................................................................... 1
Sick visit, or ............................................................................................. 3
Some other reason? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(CV1400)
(CV1400)
(CV1400)
(CV1400)
CV0600. At this visit, what was your child’s weight?
WEIGHT MEASURED..............................................................................
WEIGHT NOT MEASURED .....................................................................
1
2 (CV0800)
CV0700. (At this visit, what was your child’s weight?)
|___|___|
POUNDS
OR
|___|___|.|__|
KILOGRAMS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV0800. At this visit, what was your child’s length?
LENGTH/HEIGHT MEASURED ...............................................................
LENGTH/HEIGHT NOT MEASURED ......................................................
1
2 (CV1000)
CV0900. (At this visit, what was your child’s length?)
|___|___|.|__|
INCHES
OR
|___|___|.|__|
CENTIMETERS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV1000. At this visit, what was your child’s head circumference?
HEAD CIRCUMFERENCE MEASURED..................................................
HEAD CIRCUMFERENCE NOT MEASURED .........................................
1
2 (CV1200)
Appendix A
A.1.4.d–31
Version 1/20/08
Visit Type: 12 Month
Target: Female
CV1100. (At this visit, what was your child’s head circumference?)
|___|___|.|__|
INCHES
OR
|___|___|.|__|
CENTIMETERS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV1200. Did your child receive any vaccinations at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CV1600)
REFUSED .......................................................................................... 9--97 (CV1600)
DON’T KNOW .................................................................................... 9--98 (CV1600)
CV1300. What did {he/she} receive? What was the lot number for the vaccine your child received?
RECEIVED
YES
NO
Hepatitis B ................................................................................................
Diphtheria, Tetanus, and Pertussis (DTaP) ..............................................
H. Influenza Type B (Hib) .........................................................................
Inactivated Polio (IPV) ..............................................................................
Pneumococcal Conjugate (PCV7)............................................................
Measles, Mumps, and Rubella (German measles)...................................
Varicella (Chickenpox) .............................................................................
Hepatitis A ................................................................................................
Influenza...................................................................................................
Rotavirus ..................................................................................................
Meningococcal .........................................................................................
Other (SPECIFY):___________________________________________
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
CV1400. Did a doctor or other health care provider give your child a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CV1600)
REFUSED .......................................................................................... 9--97 (CV1600)
DON’T KNOW .................................................................................... 9--98 (CV1600)
LOT NUMBER
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Appendix A
A.1.4.d–32
Version 1/20/08
Visit Type: 12 Month
Target: Female
CV1500. What was the diagnosis?
INTERVIEWER INSTRUCTION:
ENTER ALL DIAGNOSES IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
DIAGNOSES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV1600. Did your child receive any treatments at this visit?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CV1800)
REFUSED .......................................................................................... 9--97 (CV1800)
DON’T KNOW .................................................................................... 9--98 (CV1800)
CV1700. What treatments did {he/she} receive?
INTERVIEWER INSTRUCTION:
ENTER ALL TREATMENTS IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV1800 If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Infant Medical
Care Log. Has your child had any other visits to a doctor or other health care provider since {MONTH}? Please
include routine well visits, as well as visits to a doctor or other health care provider either at a clinic, doctor’s office
or HMO, emergency room, or outpatient department for any other reason.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EL_CV01)
REFUSED .......................................................................................... 9--97 (EL_CV01)
DON’T KNOW .................................................................................... 9--98 (EL_CV01)
END LOOP CV01
LOOP:
IF CV1800 = “1,” CYCLE AGAIN.
OTHERWISE, END LOOP AND CONTINUE WITH CV1900.
Appendix A
A.1.4.d–33
Version 1/20/08
Visit Type: 12 Month
Target: Female
CV1900. Since {MONTH} has your child spent at least one night in the hospital?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX CV04)
REFUSED .......................................................................................... 9--97 (BOX CV04)
DON’T KNOW .................................................................................... 9--98 (BOX CV04)
BEGIN LOOP CV02
LOOP:
CYCLE THROUGH CV2000–CV2600 FOR EACH HOSPITALIZATION.
CV2000. What was the admission date of your child’s {next} most recent hospitalization?
INTERVIEWER INSTRUCTION:
ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR.
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV2100. How many nights did your child stay at the hospital during this hospitalization?
|___|___|___|
NUMBER OF NIGHTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV2200. Did a doctor or other health care provider give your child a diagnosis?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CV2400)
REFUSED .......................................................................................... 9--97 (CV2400)
DON’T KNOW .................................................................................... 9--98 (CV2400)
CV2300. What was the diagnosis?
INTERVIEWER INSTRUCTION:
ENTER ALL DIAGNOSES IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
DIAGNOSES
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.d–34
Version 1/20/08
Visit Type: 12 Month
Target: Female
CV2400. Did your child receive any treatments? Please include any vaccinations your child may have received.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (CV2600)
REFUSED .......................................................................................... 9--97 (CV2600)
DON’T KNOW .................................................................................... 9--98 (CV2600)
CV2500. What treatments did your child receive?
INTERVIEWER INSTRUCTION:
ENTER ALL TREATMENTS IN FIELD SEPARATED BY COMMAS OR AN “AND”.
_____________________________________________________
TREATMENTS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
CV2600. If you haven’t yet, put a check mark in the box next to the visit that you just told me about in your Infant Medical
Care Log. Has your child had any other hospitalizations since {MONTH}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP CV02
LOOP:
IF CV2600 = “1,” CYCLE AGAIN.
OTHERWISE, CONTINUE WITH NEXT SECTION.
Appendix A
A.1.4.d–35
Version 1/20/08
Visit Type: 12 Month
Target: Mother
12-Month Visit: Use of Medicines, Supplements, and Alternative Medicines
MU0100.Next, I’d like to update some information you provided during your last visit in {MONTH} about prescription and
over-the-counter medications and supplements that you have given to your child.
MU0200.May I please see the containers for any prescription and non-prescription medicines and supplements that you
gave to your child since {MONTH}? I’ll ask about prescription medications first.
RESPONDENT HAS CONTAINERS........................................................
RESPONDENT DOES NOT HAVE CONTAINERS..................................
1
2
BOX MU01
CHECK ITEM:
IF NO RECORDS WHERE UM1000, MU1200, OR MU0300 != “2” AT LAST IN
PERSON INTERVIEW, GO TO MU0600.
BEGIN LOOP MU01
LOOP:
FOR EACH RECORD WHERE UM1000 != “2” OR MU0300 != “2” OR MU1200 !=
“2” AT LAST IN-PERSON INTERVIEW, CYCLE THROUGH MU0300-MU0500.
MU0300.Are you still giving {CHILD} {MEDICATION}?
YES .......................................................................................................... 1 (EL_MU01)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (EL_MU01)
DON'T KNOW .................................................................................... 9--98 (EL_MU01)
MU0400.On what date did you stop giving {CHILD} {MEDICATION}?
INTERVIEWER INSTRUCTION:
ENTER A TWO-DIGIT MONTH, TWO-DIGIT DAY, AND A FOUR-DIGIT YEAR.
IF RESPONDENT KNOWS MONTH AND YEAR, BUT NOT DAY, ENTER 15 FOR DAY.
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
MU0500.DID RESPONDENT GIVE DATE?
RESPONDENT GAVE COMPLETE DATE ..............................................
INTERVIEWER ENTERED 15 FOR DAY.................................................
1
2
Appendix A
A.1.4.d–36
Version 1/20/08
Visit Type: 12 Month
Target: Mother
END LOOP MU01
LOOP:
IF MORE RECORDS WHERE UM1000 != “2” OR MU0300 != “2” OR MU1200 !=
“2” AT LAST IN-PERSON INTERVIEW, CYCLE AGAIN.
OTHERWISE, CONTINUE WITH MU0600.
MU0600.At any time between {MONTH} and today, have you giving your child any new medications for which a
prescription is needed? Include only those products prescribed by a health professional such as a doctor or
dentist. Please include prescription vitamins or minerals and prescriptions that you started giving to your child
since {MONTH} but are no longer taking. Prescription medications and supplements may include products like
antibiotics for ear infections, or iron supplements prescribed by a doctor.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX MU02)
REFUSED .......................................................................................... 9--97 (BOX MU02)
DON’T KNOW .................................................................................... 9--98 (BOX MU02)
MU0700.{Please show me any prescription medications you have given to your child since {MONTH}/Please tell me the
names of the prescription medications and supplements you have given to your child since {MONTH}.}
PROBE: Have you given your child any other prescription medications since {MONTH} that we missed? Please
include prescriptions you may not be currently giving, but has finished since {MONTH}.
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER.
ACTIVATE LOOKUP AND SELECT MEDICATIONS FROM LIST. CHECK TO MAKE SURE THAT BOTH THE
BRAND AND TYPE OR FORMULA MATCH. IF A MEDICATION IS NOT ON LIST, ENTER THE FULL NAME
(INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
CONFIRM ALL MEDICATIONS ENTERED BEFORE MOVING TO NEXT SCREEN.
PRODUCT ON PRESCRIPTION MEDICINE LIST .................................. 1
PRODUCT NOT ON LIST (SPECIFY): __________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BEGIN LOOP MU02
LOOP:
CYCLE THROUGH MU0800–MU1200 FOR EACH NEW PRESCRIPTION ON
ROSTER.
MU0800.{First/Next}, let’s talk about {MEDICATION}.
MU0900.PRODUCT LABEL SEEN?
YES ..........................................................................................................
NO ............................................................................................................
1
2
Appendix A
A.1.4.d–37
Version 1/20/08
Visit Type: 12 Month
Target: Mother
MU1000.RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK:
How is the {MEDICATION} taken:
By mouth, ................................................................................................ 01
Inhaled either by mouth or nose, .............................................................. 02
Injected,.................................................................................................... 03
Applied to the skin, such as a patch or creams, or ................................... 04
Some other way? (SPECIFY): _________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MU1100.When did you start giving your child {MEDICATION}:
Within the last month, ............................................................................... 1
1–3 months ago, or .................................................................................. 2
More than 3 months ago?......................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MU1200.Are you still giving {CHILD} {MEDICATION}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP MU02
LOOP:
CYCLE THROUGH MU0800–MU1200 FOR THE NEXT PRESCRIPTION
MEDICATION IN ROSTER.
WHEN FINISHED WITH ALL MEDICATIONS LISTED IN ROSTER CONTINUE
WITH BOX MU02.
BOX MU02
CHECK ITEM:
IF NO RECORDS WHERE UM1700 != “2” OR MU1300 != “2” OR MU2600 FROM
LAST IN PERSON INTERVIEW, GO TO MU1500.
BEGIN LOOP MU03
LOOP:
FOR EACH RECORD WHERE UM1800, MU1600, OR MU2600 != “2” AT LAST
IN-PERSON INTERVIEW, CYCLE THROUGH MU1300-MU1400.
Appendix A
A.1.4.d–38
Version 1/20/08
Visit Type: 12 Month
Target: Mother
MU1300.Are you still giving your child {PRODUCT}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MU1400.Since {MONTH} how often have you given your child {PRODUCT}:
Less than once a month, .......................................................................... 01
Once a month,.......................................................................................... 02
2–3 times a month (but less than once a week), ...................................... 03
1–2 times a week, .................................................................................... 04
3–4 times a week, .................................................................................... 05
5–6 times a week, or ................................................................................ 06
Every day? ............................................................................................... 07
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP MU03
LOOP:
IF MORE RECORDS WHERE UM1700, MU1300, OR MU2200 != “2” FROM
LAST IN-PERSON INTERVIEW, CYCLE AGAIN.
OTHERWISE, CONTINUE WITH MU1500.
MU1500.At any time between {MONTH} and today, have you given your child any new over-the-counter or nonprescription
medications, or any nonprescription vitamins, minerals, herbals, or dietary supplements? Over-the-counter
medications include products you buy without a doctor’s prescription and may give to your child for a cold or
cough, fever, or fussiness or irritability.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
Appendix A
A.1.4.d–39
Version 1/20/08
Visit Type: 12 Month
Target: Mother
MU1600.{Please show me any over-the-counter medications and non-prescription vitamins, minerals, herbals, or other
dietary supplements you have given your child since {MONTH}./Please tell me the names of the over-the-counter
medications and non-prescription vitamins, minerals, herbals, or other dietary supplements that you have given
your child since {MONTH}.}
PROBE: Have you given {CHILD} any other over-the-counter medications or nonprescription vitamins, minerals,
herbals, or other dietary supplements since {MONTH} that we missed?
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER.
ACTIVATE LOOKUP AND SELECT MEDICATIONS FROM LIST. CHECK TO MAKE SURE THAT BOTH THE
BRAND AND TYPE OR FORMULA MATCH. IF A MEDICATION IS NOT ON LIST, ENTER THE FULL NAME
(INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
CONFIRM ALL MEDICATIONS ENTERED BEFORE MOVING TO NEXT SCREEN.
PRODUCT ON PRESCRIPTION MEDICINE LIST .................................. 1
PRODUCT NOT ON LIST (SPECIFY): __________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BEGIN LOOP MU04
LOOP:
CYCLE THROUGH MU2000–MU2200 FOR EACH OTC ON ROSTER.
MU1700.{First/Next}, let’s talk about {PRODUCT}.
MU1800.WAS PRODUCT LABEL SEEN?
YES ..........................................................................................................
NO ............................................................................................................
1
2
MU1900.RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK:
How is this {PRODUCT} taken:
By mouth, ................................................................................................ 01
Inhaled either by mouth or nose, .............................................................. 02
Injected,.................................................................................................... 03
Applied to the skin, such as a patch or creams, or ................................... 04
Some other way? (SPECIFY): _________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–40
Version 1/20/08
Visit Type: 12 Month
Target: Mother
MU2000.When did you start giving your child {PRODUCT}:
Within the last month, ............................................................................... 1
1–3 months ago, or .................................................................................. 2
More than 3 months ago?......................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MU2100.Since {MONTH}, how often have you given your child {PRODUCT}:
Less than once a month, .......................................................................... 01
Once a month,.......................................................................................... 02
2–3 times a month (but less than once a week), ...................................... 03
1–2 times a week, .................................................................................... 04
3–4 times a week, .................................................................................... 05
5–6 times a week, or ................................................................................ 06
Every day? ............................................................................................... 07
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
MU2200.Are you still giving {CHILD} {PRODUCT}?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP MU04
LOOP:
CYCLE THROUGH MU1700–MU2200 FOR THE NEXT OTC IN ROSTER.
WHEN FINISHED WITH ALL OTCS LISTED IN ROSTER CONTINUE WITH
NEXT SECTION.
Appendix A
A.1.4.d–41
Version 1/20/08
Visit Type: 12 Month
Target: Mother
12-Month Visit: Alternative/Traditional Medicines
AM0100.The next questions ask about traditional medicines, home remedies, and beauty products made in other countries
and sent to the United States.
AM0200.Since {MONTH}, did you give your child any traditional medicines or home remedies to treat stomach ache,
vomiting, colic, empacho (stomach ache or vomiting), or to aid digestion?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (AM0500)
REFUSED .......................................................................................... 9--97 (AM0500)
DON’T KNOW .................................................................................... 9--98 (AM0500)
AM0300.Which traditional medicines or home remedies have you given your child?
SELECT ALL THAT APPLY.
SHOW CARD PR2.
ALBAYALDE (ALBAYAIDLE) ................................................................... 01
AZARCON (RUEDA, CORAL, MARIA LUISA, ALARCON, LIGA, LUIGA) . 02
BALI GOLI ................................................................................................ 03
GHASARD................................................................................................ 04
GRETA ..................................................................................................... 05
KANDU..................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 94
OTHER (SPECIFY): _________________________________________ 95
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HELP SCREEN:
Albayalde: Albayalde is a white powder also known as albayaidle that comes from Mexico, Cuba, Puerto Rico, or
other parts of Central or South America that is sometimes given to children for colic or empacho (stomach ache or
vomiting).
Azarcon: Azarcon is a bright red-orange powder also known as Rueda, Coral, Maria Luisa, Alarcon, Liga, or Luiga
that comes from Mexico, Cuba, Puerto Rico, or other parts of Central or South America that is sometimes given to
children for colic or empacho (stomach ache or vomiting).
Bali Goli: Bali Goli is a round, flat bean given in “gripe” water that comes from India or Southeast Asia that is
sometimes given to children for colic, stomach ache, or to aid digestion.
Ghasard: Ghasard is a brown powder that comes from India or Southeast Asia that is sometimes given to children
for colic, stomach ache, or to aid digestion.
Greta: Greta is a yellow powder that comes from Mexico, Cuba, Puerto Rico, or other parts of Central or South
America that is sometimes given to children for colic or empacho (stomach ache or vomiting).
Kandu: Kandu is a red powder that comes from India or Southeast Asia that is sometimes given to children for
colic, stomach ache, or to aid digestion.
Appendix A
A.1.4.d–42
Version 1/20/08
Visit Type: 12 Month
Target: Mother
BEGIN LOOP PR01
LOOP:
FOR EACH YES RESPONSE IN AM0300, ASK AM0400.
AM0400.How often did you give your child {READ NAME OF YES RESPONSE}?
Once a month or less ............................................................................... 1
2–3 times a month.................................................................................... 2
Once a week ............................................................................................ 3
2–3 times a week ..................................................................................... 4
4–6 times a week ..................................................................................... 5
Every day ................................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP PR01
LOOP:
IF MORE YES RESPONSES, ASK AM0400 AGAIN.
IF AM0400 ASKED FOR ALL YES RESPONSES IN AM0300, END LOOP.
AM0500 Since {MONTH}, did you give your child any traditional medicines or home remedies to treat a skin condition or
rash?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (AM0800)
REFUSED .......................................................................................... 9--97 (AM0800)
DON’T KNOW .................................................................................... 9--98 (AM0800)
AM0600.Which traditional medicines or home remedies have you given your child?
SELECT ALL THAT APPLY.
SHOW CARD PR3.
KOHL (ALKOHL, TIRO, SURMA, SAOTT)............................................... 01
LITARGIRIO ............................................................................................. 02
PAYLOOAH (PEJLUAM, PE LUA) ........................................................... 03
OTHER (SPECIFY): _________________________________________ 94
OTHER (SPECIFY): _________________________________________ 95
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–43
Version 1/20/08
Visit Type: 12 Month
Target: Mother
HELP SCREEN:
Kohl: Kohl is a black powder also called Alkohl, Tir, Surma, or Saott that comes from India, Pakistan, the Middle
East or Africa that is sometimes used on a child’s belly button (umbilical cord) to treat an injury or skin infection.
Litargirio: Litargirio is a yellow- or peach-colored powder that comes from Mexico, Cuba, Puerto Rico, or other
parts of Central or South America that is used as a deodorant or foot powder or as a treatment for burns, cuts,
and other conditions.
Paylooah: Paylooah comes from India or Southeast Asia and is sometimes used to treat a rash, fever, or other
condition.
BEGIN LOOP PR02
LOOP:
FOR EACH YES RESPONSE IN AM0600, ASK AM0700.
AM0700.How often did you give your child {READ NAME OF YES RESPONSE}?
Once a month or less ............................................................................... 1
2–3 times a month.................................................................................... 2
Once a week ............................................................................................ 3
2–3 times a week ..................................................................................... 4
4–6 times a week ..................................................................................... 5
Every day ................................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP PR02
LOOP:
IF MORE YES RESPONSES, ASK AM0700 AGAIN.
IF AM0700 ASKED FOR ALL YES RESPONSES IN AM0600, END LOOP.
AM0800.Since {MONTH}, did you give your child any traditional medicines or home remedies to treat a fever or infection?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (AM1100)
REFUSED .......................................................................................... 9--97 (AM1100)
DON’T KNOW .................................................................................... 9--98 (AM1100)
Appendix A
A.1.4.d–44
Version 1/20/08
Visit Type: 12 Month
Target: Mother
AM0900.Which traditional medicines or home remedies have you given your child?
SELECT ALL THAT APPLY.
SHOW CARD PR4.
KOHL (ALKOHL, TIRO, SURMA, SAOTT)............................................... 01
PAYLOOAH (PEJLUAM, PE LUA) ........................................................... 02
OTHER (SPECIFY): _________________________________________ 94
OTHER (SPECIFY): _________________________________________ 95
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
HELP SCREEN:
Kohl: Kohl is a black powder also called Alkohl, Tir, Surma, or Saott that comes from India, Pakistan, the Middle
East or Africa that is sometimes used on a child’s belly button (umbilical cord) to treat an injury or skin infection.
Paylooah: Paylooah comes from India or Southeast Asia and is sometimes used to treat a rash, fever, or other
condition.
BEGIN LOOP PR03
LOOP:
FOR EACH YES RESPONSE IN AM0900, ASK AM1000.
AM1000.How often did you give your child {READ NAME OF YES RESPONSE}?
Once a month or less ............................................................................... 1
2–3 times a month.................................................................................... 2
Once a week ............................................................................................ 3
2–3 times a week ..................................................................................... 4
4–6 times a week ..................................................................................... 5
Every day ................................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP PR03
LOOP:
IF MORE YES RESPONSES, ASK AM1000 AGAIN.
IF AM1000 ASKED FOR ALL YES RESPONSES IN AM0900, END LOOP.
AM1100.Since {MONTH}, did you give your child any traditional medicines or home remedies for any other reason?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
Appendix A
A.1.4.d–45
Version 1/20/08
Visit Type: 12 Month
Target: Mother
AM1200.Which traditional medicines or home remedies have you given your child?
SELECT ALL THAT APPLY.
SHOW CARD PR5.
ALBAYALDE (ALBAYAIDLE) ................................................................... 01
AZARCON (RUEDA, CORAL, MARIA LUISA, ALARCON, LIGA, LUIGA) . 02
BALI GOLI ................................................................................................ 03
GHASARD................................................................................................ 04
GRETA ..................................................................................................... 05
KANDU..................................................................................................... 06
LITARGIRIO ............................................................................................. 02
KOHL (ALKOHL, TIRO, SURMA, SAOTT)............................................... 01
PAYLOOAH (PEJLUAM, PE LUA) ........................................................... 02
OTHER (SPECIFY): _________________________________________ 94
OTHER (SPECIFY): _________________________________________ 95
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BEGIN LOOP PR04
LOOP:
FOR EACH YES RESPONSE IN AM1200, ASK AM1300 AND AM1400.
AM1300.What was the reason you gave your child {READ NAME OF YES RESPONSE}?
_________________________________________________________
REASON
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
AM1400.How often did you give your child {READ NAME OF YES RESPONSE}?
Once a month or less ............................................................................... 1
2–3 times a month.................................................................................... 2
Once a week ............................................................................................ 3
2–3 times a week ..................................................................................... 4
4–6 times a week ..................................................................................... 5
Every day ................................................................................................. 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–46
Version 1/20/08
Visit Type: 12 Month
Target: Mother
END LOOP PR04
LOOP:
IF MORE YES RESPONSES, ASK AM1300–AM1400 AGAIN.
IF AM1300-AM1400 ASKED FOR ALL YES RESPONSES IN AM1200, END
LOOP.
Appendix A
A.1.4.d–47
Version 1/20/08
Visit Type: 12 Month
Target: Mother
12-Month Visit: Product Use
PR0100. These questions ask about some different types of products you may have used to take care of yourself, your
family, or your home. Please choose your answer from one of these categories.
SHOW CARD PR1.
PR0200. Since {MONTH}, how often have the following products been used in your home:
SHOW CARD PR1.
LESS
ABOUT
1–3
THAN
A FEW ONCE TIMES
ONCE
EVERY TIMES
A
A
A
DAY A WEEK WEEK MONTH MONTH
a. Bleach? ..........................................
b. Disinfectants other than bleach,
such as Lysol? ...............................
c. Window or glass cleaner? ..............
d. Carpet cleaner?..............................
e. Any type of air fresheners including
spray, stick, aerosol, or plug-in?.....
f. Other aerosols or sprays of any
kind, including hair spray?..............
g. Paint or varnish? ............................
h. Turpentine, mineral spirits, or
paint thinner? .................................
i. Other types of paint stripper? .........
NOT
AT ALL
RF
DK
01
02
03
04
05
06
9--97 9--98
01
01
01
02
02
02
03
03
03
04
04
04
05
05
05
06
06
06
9--97 9--98
9--97 9--98
9--97 9--98
01
02
03
04
05
06
9--97 9--98
01
01
02
02
03
03
04
04
05
05
06
06
9--97 9--98
9--97 9--98
01
01
02
02
03
03
04
04
05
05
06
06
9--97 9--98
9--97 9--98
PR0300. Since {MONTH}, about how often have candles or incense been burned inside your home?
Every day, ................................................................................................ 01
A few times a week, ................................................................................. 02
About once a week, .................................................................................. 03
1–3 times a month, .................................................................................. 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–48
Version 1/20/08
Visit Type: 12 Month
Target: Mother
PR0400. Since {MONTH}, about how often have you used scented products for your home such as scented laundry
detergents, fabric softener, or dish soaps? Do not include air fresheners, candles, or incense.
Every day, ................................................................................................ 01
A few times a week, ................................................................................. 02
About once a week, .................................................................................. 03
1–3 times a month, .................................................................................. 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR0500. The next questions ask about the types of diapers you use on your child.
PR0600.Since {MONTH}, about how often did you put each of the following types of diapers on your child?
Fill in one circle for each statement that describes a type of diaper.
NEVER
Disposable diapers.........................
Cloth diapers cleaned by a
professional diaper service...........
Cloth diapers cleaned at home.......
ABOUT
HALF OF
SOMETIMES THE TIME
MOST OF
THE TIME
ALWAYS RF
DK
1
2
3
4
5
9--97 9--98
1
1
2
2
3
3
4
4
5
5
9--97 9--98
9--97 9--98
PR0700. Since {MONTH}, about how often did you use each of the following types of baby wipes on your child?
Fill in one circle for each statement that describes a type of baby wipe.
NEVER
Scented Baby Wipes ........................................
Unscented Baby Wipes ....................................
1
1
OCCASIONALLY
2
2
OFTEN ALWAYS
3
3
PR0900. Does {CHILD} use a pacifier?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (BOX PR01)
REFUSED .......................................................................................... 9--97 (BOX PR01)
DON’T KNOW .................................................................................... 9--98 (BOX PR01)
PR1000.How many hours a day does {CHILD} use {his/her} pacifier?
Less than 1 hour,...................................................................................... 1
1–2 hours, ................................................................................................ 2
2–5 hours, or ............................................................................................ 3
6 or more hours? ...................................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
4
4
RF
DK
9--97 9--98
9--97 9--98
Appendix A
A.1.4.d–49
Version 1/20/08
Visit Type: 12 Month
Target: Mother
BOX PR01
CHECK ITEM:
IF R NEVER BREASTFED, GO TO PR1300.
OTHERWISE, CONTINUE.
PR1100.Since {MONTH}, about how often did you put a breast nipple cream, salve, or balm on your nipples to prevent or
treat sore or tender nipples?
Every day when breastfeeding, ................................................................ 01
A few times a week when breastfeeding, ................................................. 02
About once a week when breastfeeding,.................................................. 03
1–3 times a month when breastfeeding.................................................... 04
Less than once a month when breastfeeding, or...................................... 05
Not at all? ................................................................................................. 06 (PR1000)
REFUSED .......................................................................................... 9--97 (PR1000)
DON’T KNOW .................................................................................... 9--98 (PR1000)
PR1200.Which of the following types of breast nipple cream, salve, or balm did you use most often on your breasts?
A petroleum based product such as Vaseline, ......................................... 01
A lanolin based product, ........................................................................... 02
Soothing gel pads, or .............................................................................. 03
Other type of product? (SPECIFY):)_____________________________ 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR1300.Since {MONTH}, about how often have you used any insect repellent spray, lotion, or towelettes on {CHILD}?
Every day, ................................................................................................ 01
A few times a week, ................................................................................. 02
About once a week, .................................................................................. 03
1–3 times a month, .................................................................................. 04
Less than once a month, or ...................................................................... 05
Not at all? ................................................................................................. 06
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR1400.Did the insect repellent contain DEET? (DEET is usually listed next to the name of the product or in the ingredient
list on the label.)
YES .......................................................................................................... 1
NO ............................................................................................................ 2
USED BOTH REPELLENT WITH DEET AND WITHOUT DEET ............. 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–50
Version 1/20/08
Visit Type: 12 Month
Target: Mother
PR1500.Since {MONTH}, have you treated {CHILD} or other people in your home for lice or scabies?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
PR1600.Who did you treat, was it {CHILD}, someone else, or both?
BABY........................................................................................................ 1
SOMEONE ELSE..................................................................................... 2
BOTH BABY AND SOMEONE ELSE .......................................................
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
PR1700.What product did you use to treat lice or scabies?
PROBE: Anything else?
SELECT ALL THAT APPLY.
NIX ........................................................................................................... 01
RID ........................................................................................................... 02
GENERIC/DRUGSTORE BRAND LICE/SCABIES PRODUCT................ 03
ELIMITE ................................................................................................... 04
ACTICIN ................................................................................................... 05
EURAX ..................................................................................................... 06
KWELL/KWELLEDA................................................................................. 07
OVIDE ...................................................................................................... 08
STROMECTOL ........................................................................................ 09
OTHER (SPECIFY: _________________________________________ 94
OTHER (SPECIFY: _________________________________________ 95
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–51
Version 1/20/08
Visit Type: 12 Month
Target: Mother
12-Month Visit: In-Home Exposures
EX0100. Now I’d like to ask about any pets you may have in your home.
EX0200. Are there any pets that spend any time inside your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EX0900)
REFUSED .......................................................................................... 9--97 (EX0900)
DON’T KNOW .................................................................................... 9--98 (EX0900)
EX0300.What kind of pets are these?
SELECT ALL THAT APPLY.
DOG ......................................................................................................... 01
CAT .......................................................................................................... 02
SMALL MAMMAL (RABBIT, GERBIL, HAMSTER, GUINEA PIG,
FERRET, MOUSE)................................................................................ 03
BIRD......................................................................................................... 04
FISH OR REPTILE (TURTLE, SNAKE, LIZARD)..................................... 05
OTHER (SPECIFY): _________________________________________ 94
OTHER (SPECIFY): _________________________________________ 95
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX0400. Are any products ever used on your pets to control fleas, ticks, or mites? This includes flea collars, flea and tick
powders, shampoos, or other flea, tick and mite control products. (This does not include pills given to your pet to
control for fleas or other insects.)
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EX0700)
REFUSED .......................................................................................... 9--97 (EX0700)
DON’T KNOW .................................................................................... 9--98 (EX0700)
EX0500. When were any of these last used on any of your pets:
Within the last month, ............................................................................... 1
1–3 months ago,....................................................................................... 2
4–6 months ago, or .................................................................................. 3
More than 6 months ago?......................................................................... 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–52
Version 1/20/08
Visit Type: 12 Month
Target: Mother
EX0600. What are the names of the products used on your pets to control fleas, ticks, or mites? Please show me the
products or containers if you have them.
_______________________________
ENTER PRODUCT NAME FROM LIST
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
EX0700. Do any of your pets go in the room where your baby sleeps most of the time?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX0800. Do any of your pets sleep on the same bedding as your baby?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX0900. What temperature did you use to wash your child’s sheets? Was it,
HOT.......................................................................................................... 1
WARM ...................................................................................................... 2
COLD ...................................................................................................... 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX1000. About how often do you wash your child’s clothes, towels, bedding, or other laundry with each of the following
items? Fill in one circle for each item listed.
LESS
ABOUT
1–3
THAN
A FEW ONCE TIMES
ONCE
EVERY TIMES
A
A
A
NOT
DAY A WEEK WEEK MONTH MONTH AT ALL RF
DK
Liquid or powder laundry soap with a
fragrance (such as lemon scent,
mountain spring, floral, clean
breeze, or other scent) ....................
Chlorine Bleach ..................................
Fabric softener or dryer sheet with
a fragrance (such as lemon scent,
mountain spring, floral, clean
breeze, or other scent) ....................
Spot or stain remover .........................
1
1
2
2
3
3
4
4
5
5
6
6
9--97 9--98
9--97 9--98
1
1
2
2
3
3
4
4
5
5
6
6
9--97 9--98
9--97 9--98
Appendix A
A.1.4.d–53
Version 1/20/08
Visit Type: 12 Month
Target: Mother
EX1100. Do you use any methods to “allergy-proof” your home? Please answer “yes” or “no” to each method I describe.
YES
NO
RF
DK
1
2
9--97
9--98
1
1
1
1
2
2
2
2
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
a. Tannic acid or other mite control chemicals? .......................................
b. Impermeable mattress and or pillow covers on your child’s bed
or crib? .................................................................................................
c. Use a special vacuum such as a HEPA vacuum?................................
d. Intentionally removed rugs or upholstered furniture? ...........................
e. Any other methods? (SPECIFY): _____________________________
EX1200. Does your furnace or air conditioning system use a special HEPA (High Efficiency Particulate Air) or other type of
allergy filter to filter the air?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX1300. Thinking about the past 7 days, approximately how many hours a day did you keep the windows or doors open in
your home (for ventilation or to let air in)? Was it:
Less than 1 hour per day,......................................................................... 1
1–3 hours per day, ................................................................................... 2
4–12 hours per day, ................................................................................. 3
More than 12 hours per day, or ................................................................ 4
Not at all? ................................................................................................. 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX1400. I would now like to ask about products that may have been used in your home or yard to control for ants, termites,
cockroaches, bees, wasps, moths, or other insects during the past 6 months.
EX1500. When were any pesticides last used inside or outside your home to control for insects?
Within the last month, ............................................................................... 1
1–3 months ago,....................................................................................... 2
4–6 months ago,....................................................................................... 3
More than 6 months ago, or ..................................................................... 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(EX2000)
(EX2000)
(EX2000)
(EX2000)
Appendix A
A.1.4.d–54
Version 1/20/08
Visit Type: 12 Month
Target: Mother
EX1600. In preparation for this interview, we asked that you gather together the pesticide cans or containers that have
been used in the last 6 months. You may also have letters from building maintenance about pesticide application,
or receipts from the exterminator that list which products were used. Please show me, or tell me the names of the
products that have been used within the last 6 months, either indoors or outdoors, to treat for insects?
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT, LETTER, OR RECEIPT IS PROVIDED.
_________________________
PRODUCT NAME FROM LIST
_________________________
REGISTRATION NUMBER IF KNOWN
REFUSED .................................................................................. 9--97 (EOS)
DON’T KNOW ............................................................................ 9--98 (EOS)
BEGIN LOOP EX01
LOOP:
CYCLE THROUGH EX1700-EX1900 FOR ALL INSECTICIDE PRODUCTS
LISTED IN EX1600.
EX1700. How was the {PRODUCT} applied?
SELECT ALL THAT APPLY.
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT IS PROVIDED.
SPRAY ..................................................................................................... 01
BOMB....................................................................................................... 02
POWDER ................................................................................................. 03
STRIP....................................................................................................... 04
MOTH BALLS........................................................................................... 05
FOAM ....................................................................................................... 06
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–55
Version 1/20/08
Visit Type: 12 Month
Target: Mother
EX1800.Which of the following areas of your home were treated with {PRODUCT}? Was it…
INTERVIEWER INSTRUCTION:
SELECT “NA” FOR EACH ROOM OR AREA R REPORTS THAT THEY DO NOT HAVE.
a. The common living area, that is the room other than
bedroom or kitchen where you spend most of your time?......
b. The kitchen? ..........................................................................
c. Your bedroom? ......................................................................
d. The basement? ......................................................................
e. Any other rooms?...................................................................
f. Outdoors, around the walls of your house or building? ..........
g. Outdoors, in the garden or yard? ...........................................
h. (IF R LIVES IN SINGLE FAMILY HOME, RECORD “NA”
WITHOUT ASKING) Common areas inside building but
outside of your home or apartment (public foyer or
hallway, etc.)? ........................................................................
YES
NO
NA
RF
DK
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
1
2
3
9--97
9--98
EX1900. How often was the {PRODUCT} used in the past 6 months:
More than once a month, or ..................................................................... 1
Once a month or less? ............................................................................. 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP EX01
LOOP:
CYCLE THROUGH EX1700–EX1900 FOR NEXT INSECTICIDE PRODUCT.
IF NO MORE PRODUCTS, GO TO EX2000.
EX2000. Since {MONTH}, have you seen signs of mice, rats, or other rodents in your home (not including pets)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX2100. Since {MONTH}, have you seen cockroaches in your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX2200. Water damage is a common problem that occurs inside of many homes. Water damage includes water stains on
the ceiling or walls, rotting wood, and flaking sheetrock or plaster. This damage may be from broken pipes, a
leaky roof, or floods.
Appendix A
A.1.4.d–56
Version 1/20/08
Visit Type: 12 Month
Target: Mother
EX2300. Since {MONTH}, have you seen any water damage inside your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX2400. Since {MONTH}, have you seen any mold or mildew on walls or other surfaces, other than the shower or bathtub,
inside your home?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EX2600)
REFUSED .......................................................................................... 9--97 (EX2600)
DON’T KNOW .................................................................................... 9--98 (EX2600)
EX2500. In which rooms have you seen the mold or mildew?
PROBE: Any other rooms?
SELECT ALL THAT APPLY.
KITCHEN.................................................................................................. 01
LIVING ROOM ......................................................................................... 02
HALL/LANDING ....................................................................................... 03
RESPONDENT’S BEDROOM.................................................................. 04
OTHER BEDROOM ................................................................................. 05
BATHROOM/TOILET ............................................................................... 06
BASEMENT.............................................................................................. 07
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX2600. The next few questions ask about any recent additions or renovations to your home.
EX2700. Since {MONTH}, have any additions been built onto your home to make it bigger?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX2800. Since {MONTH}, have any renovations or other construction been done in your home? Include only major
projects. Do not count smaller projects that were just painting or wall papering.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EX3000)
REFUSED .......................................................................................... 9--97 (EX3000)
DON’T KNOW .................................................................................... 9--98 (EX3000)
Appendix A
A.1.4.d–57
Version 1/20/08
Visit Type: 12 Month
Target: Mother
EX2900. Which rooms were renovated?
PROBE: Any others?
SELECT ALL THAT APPLY.
KITCHEN.................................................................................................. 01
LIVING ROOM ......................................................................................... 02
HALL/LANDING ....................................................................................... 03
RESPONDENT’S BEDROOM.................................................................. 04
OTHER BEDROOM ................................................................................. 05
BATHROOM/TOILET ............................................................................... 06
BASEMENT.............................................................................................. 07
OTHER (SPECIFY): _________________________________________ 08
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX3000. Now I’d like to ask about the water in your home.
EX3100. What water source in your home do you use most of the time for drinking:
Tap water, ................................................................................................ 1
Filtered tap water,..................................................................................... 2
Bottled water, or ....................................................................................... 3
Some other source? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX3200. What water source in your home is used most of the time for cooking:
Tap water, ................................................................................................ 1
Filtered tap water,..................................................................................... 2
Bottled water, or ....................................................................................... 3
Some other source? (SPECIFY): _______________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
EX3300. Now, a couple of questions about your neighborhood.
EX3400. In your opinion, is your neighborhood…
A very good place to live, ......................................................................... 1
A fairly good place to live,......................................................................... 2
Not a very good place to live, or ............................................................... 3
Not at all a good place to live? ................................................................. 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–58
Version 1/20/08
Visit Type: 12 Month
Target: Mother
EX3500. Do you feel that your neighborhood is…
Very safe, ................................................................................................. 1
Somewhat safe,........................................................................................ 2
Somewhat unsafe, or ............................................................................... 3
Very unsafe? ............................................................................................ 4
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–59
Version 1/20/08
Visit Type: 12 Month
Target: Male, Female
12-Month Visit: Occupational/Hobby Exposures
OU0100.Now I would like to update some information about schoolwork, jobs, volunteer work, and hobbies that you have
done recently.
Please only include activities that you do or have done for 4 hours a week or longer.
OU0200.Are you currently a full- or part-time student? This includes vocational or technical schooling that may not be done
in a classroom.
PROBE: Do you go full-time or part-time?
NO, NOT A STUDENT ............................................................................. 1 (BOX OU01)
YES, FULL-TIME STUDENT.................................................................... 2
YES, PART-TIME STUDENT ................................................................... 3
REFUSED .......................................................................................... 9--97 (BOX OU01)
DON’T KNOW .................................................................................... 9--98 (BOX OU01)
OU0300.What type or types of school are you currently attending?
SELECT ALL THAT APPLY.
HIGH SCHOOL ........................................................................................ 1
TECHNICAL SCHOOL ............................................................................. 2
COLLEGE OR UNIVERSITY.................................................................... 3
GRADUATE SCHOOL ............................................................................. 4
PROFESSIONAL SCHOOL (E.G., MEDICAL, LAW, DENTAL) ............... 5
OTHER (SPECIFY): _________________________________________ 6
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
BOX OU01
CHECK ITEM:
IF StillAtJob, StillAtJobNew, OR StillWorkingAtSameJob = “1” AT LAST
INTERVIEW, BEGIN LOOP OU01.
OTHERWISE, GO TO OU1600.
BEGIN LOOP OU01
LOOP:
CYCLE THROUGH OU0700–OU1500 FOR EACH PREVIOUS JOB.
Appendix A
A.1.4.d–60
Version 1/20/08
Visit Type: 12 Month
Target: Male, Female
OU0700.Are you still working as a {JobTitle} for {EmployerName}?
YES .......................................................................................................... 1 (OU0900)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97 (OU0900)
DON’T KNOW .................................................................................... 9--98 (OU0900)
OU0800.On what date did you stop working at this job?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
BOX OU02
CHECK ITEM:
IF OU0700= “2,” GO TO EL_OU01.
OU0900.On average, how many hours a week do you usually work at this job?
|___|___|___|
NUMBER OF HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU1000.Does this include working a shift that starts after 2 pm?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OU1100.Do you rotate among different shifts for this job?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP OU01
LOOP:
IF MORE JOBS, CYCLE AGAIN.
OTHERWISE CONTINUE WITH OU1600.
Appendix A
A.1.4.d–61
Version 1/20/08
Visit Type: 12 Month
Target: Male, Female
OU1600.At anytime between {MONTH} and today, did you start a new job?
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (OU3200)
REFUSED .......................................................................................... 9--97 (OU3200)
DON’T KNOW .................................................................................... 9--98 (OU3200)
OU1700.Please tell me how many different full-time, part-time, or volunteer jobs you started.
Please only include activities that you do or have done for at least 4 hours per week.
a. Full-time jobs? .............................................................................
b. Part-time jobs? ............................................................................
c. Volunteer jobs (fire department, humane society, etc.)?..............
NUMBER
RF
DK
|___|___|
|___|___|
|___|___|
9--97
9--97
9--97
9--98
9--98
9--98
BOX OU02
CHECK ITEM:
ADD THE NUMBER OF FULL-TIME, PART-TIME, AND VOLUNTEER JOBS
(NumberFullTimeJobsNew (OU1700A), NumberPartTimeJobsNew (OU1700B),
AND NumberVolunteerJobsNew (OU1700C)) AND CREATE
TotalNumberOfJobsNew. DO NOT INCLUDE “9--97” OR “9--98” RESPONSES
IN THE SUM.
IF OU1700A-C ALL SOME COMBINATION OF “9--97” AND “9--98,”
TotalNumberOfJobsNew = “0”.
BOX OU03
CHECK ITEM:
IF TotalNumberOfJobsNew > “0”, BEGIN LOOP OU02.
IF TotalNumberOfJobsNew = “0”, GO TO OU3200.
BEGIN LOOP OU02
LOOP:
CYCLE THROUGH BOX OU04–OU3100 AS MANY TIMES AS THE NUMBER
CALCULATED IN TotalNumberOfJobsNew.
BOX OU04
CHECK ITEM:
IF TotalNumberOfJobsNew = “1,” GO TO OU1900.
OTHERWISE, CONTINUE WITH OU1800.
Appendix A
A.1.4.d–62
Version 1/20/08
Visit Type: 12 Month
Target: Male, Female
OU1800.{Now I’d like to ask some questions about each one of your new jobs, starting with the job where you work the
most hours/ Now think about the new job where you work the next greatest number of hours}.
OU1900.On what date did you start working at this job?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU2000.Are you currently working at this job?
YES .......................................................................................................... 1 (OU2200)
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OU2100.On what date did you stop working at this job?
|___|___|
MM
|___|___|
DD
|___|___|___|___|
YYYY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU2200.For this job, what {is/was} your job title or occupation?
_________________________________________________________
JOB TITLE
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU2300.For this job, who {is/was} your employer?
_________________________________________________________
EMPLOYER
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
Appendix A
A.1.4.d–63
Version 1/20/08
Visit Type: 12 Month
Target: Male, Female
OU2400.What types of activities {do/did} you do most often at this job? For example, teach classes, work on the computer,
keep account books, file, photocopy, answer phone, wait tables, help customers, do lab work, or carpentry.
PROBE: Anything else?
INTERVIEWER INSTRUCTION:
SEPARATE EACH ACTIVITY WITH A COMMA.
_________________________________________________________
ACTIVITY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU2500.In what kind of business or industry {is/was} this job? That is, what does this company make or do?
_________________________________________________________
INDUSTRY
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU2600.On average, how many hours a week {do/did} you usually work at this job?
|___|___|___|
NUMBER OF HOURS
REFUSED ..........................................................................................
DON’T KNOW ....................................................................................
9--97
9--98
OU2700.{{Does/Did} this include working a shift that {starts/started} after 2 pm?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OU2800.{Do/Did} you rotate among different shifts for this job?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
END LOOP OU02
LOOP:
IF NUMBER OF CYCLES < TotalNumberOfJobsNew, CYCLE THROUGH BOX
OU04–OU3100 AGAIN.
Appendix A
A.1.4.d–64
Version 1/20/08
Visit Type: 12 Month
Target: Mother
12-Month Visit: Occupation and Take Home Exposures
OX0900. Now I am going to ask you about work clothing. Some people work at jobs where their skin, clothes, or shoes get
dirty or stained. Think about everyone in your household. Does anyone ever routinely come home with dirty or
stained skin, work clothes, or shoes? By “dirty or stained” I mean their skin or clothes have dust, grease, or other
visible chemical spots on them.
YES .......................................................................................................... 1
NO ............................................................................................................ 2 (EOS)
REFUSED .......................................................................................... 9--97 (EOS)
DON’T KNOW .................................................................................... 9--98 (EOS)
OX1000. Who is it that comes home with dirty or stained skin, work clothes, or shoes? Is it:
You, .......................................................................................................... 1
Others in the home, or.............................................................................. 2
Both you and others in the home?............................................................ 3
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OX1100. How often do you or anyone in your household come home from work with dirty hands or skin?
Every day, ............................................................................................... 1
5–6 times a week, .................................................................................... 2
3–4 times a week, .................................................................................... 3
1–2 times a week, or ................................................................................ 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OX1200. How often do you or anyone in your household wear dirty work shoes inside your home?
Every day, ............................................................................................... 1
5–6 times a week, .................................................................................... 2
3–4 times a week, .................................................................................... 3
1–2 times a week, or ................................................................................ 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OX1300. How often do you or anyone in your household wear dirty work clothes inside your home?
Every day, ................................................................................................ 1
5–6 times a week, .................................................................................... 2
3–4 times a week, .................................................................................... 3
1–2 times a week, or ................................................................................ 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–65
Version 1/20/08
Visit Type: 12 Month
Target: Mother
OX1400. How often do you or anyone in your household wash work clothes at home?
Every day, ................................................................................................ 1
5–6 times a week, .................................................................................... 2
3–4 times a week, .................................................................................... 3
1–2 times a week, or ................................................................................ 4
Never?...................................................................................................... 5
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
(OX1600)
(OX1600)
(OX1600)
(OX1600)
OX1500. Are work clothes washed separately from other clothes?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
OX1600. What types of materials have you or anyone in your household brought home on work clothes or shoes?
SHOW CARD OX2.
SELECT ALL THAT APPLY.
DIRT ......................................................................................................... 01
WOOD DUST ........................................................................................... 02
GREASE .................................................................................................. 03
PESTICIDES ............................................................................................ 04
METAL DUST........................................................................................... 05
COAL OR MINING DUST......................................................................... 06
ANIMAL HAIR .......................................................................................... 07
FIBERS (SUCH AS ASBESTOS OR FIBERGLASS) ............................... 08
OTHER (SPECIFY): _________________________________________ 96
REFUSED .......................................................................................... 9--97
DON’T KNOW .................................................................................... 9--98
Appendix A
A.1.4.d–66
Version 1/20/08
Visit Type: 12 Month
Target: Mother
12-Month Visit: Language Development
LN0100. Next, I’ll read a list of words. If your child understands that word but does not yet say it, say “Understands.” If your
child understands and also says the word, say “Understands and Says.”
Include the word even if your child uses a different pronunciation of the word.
LN0200.
UNDERSTANDS
Choo choo .......................................................
Meow...............................................................
Ouch................................................................
Uh oh...............................................................
Bird ..................................................................
Dog..................................................................
Duck ................................................................
Kitty .................................................................
Lion .................................................................
Mouse..............................................................
Car ..................................................................
Stroller .............................................................
Ball ..................................................................
Book ................................................................
Doll ..................................................................
Bread...............................................................
Candy ..............................................................
Cereal..............................................................
Cookie .............................................................
Juice ................................................................
Toast ...............................................................
Hat...................................................................
Pants ...............................................................
Shoe ................................................................
Sock ................................................................
Eye ..................................................................
Head................................................................
Leg ..................................................................
Nose ................................................................
Tooth ...............................................................
Chair................................................................
Couch ..............................................................
Kitchen ............................................................
Table ...............................................................
Television ........................................................
Blanket ............................................................
Bottle ...............................................................
Cup..................................................................
Dish .................................................................
Lamp ...............................................................
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
UNDERSTANDS
AND SAYS
RF
DK
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9—98
9--98
Appendix A
A.1.4.d–67
Version 1/20/08
Visit Type: 12 Month
Target: Mother
LN0200. (continued)
UNDERSTANDS
Radio ...............................................................
Spoon ..............................................................
Flower..............................................................
Home...............................................................
Moon ...............................................................
Outside ............................................................
Plant ................................................................
Rain .................................................................
Rock ................................................................
Water...............................................................
Babysitter ........................................................
Girl...................................................................
Grandma .........................................................
Mommy............................................................
Bath .................................................................
Don’t ................................................................
Hi.....................................................................
Night night .......................................................
Patty cake........................................................
Please .............................................................
Wait .................................................................
Break ...............................................................
Feed ................................................................
Finish...............................................................
Help .................................................................
Jump ...............................................................
Kick .................................................................
Kiss .................................................................
Push ................................................................
Sing .................................................................
Smile ...............................................................
Night ................................................................
Today ..............................................................
All gone ...........................................................
Big ...................................................................
Broken .............................................................
Dark.................................................................
Fast .................................................................
Hurt .................................................................
Pretty ...............................................................
Soft ..................................................................
I .......................................................................
Me ...................................................................
How .................................................................
Who .................................................................
Away ...............................................................
Out ..................................................................
Other ...............................................................
Some ...............................................................
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
UNDERSTANDS
AND SAYS
RF
DK
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
9--98
Appendix A
A.1.4.d–68
Version 1/20/08
Visit Type: 12 Month
Target: Mother
12-Month Visit: Financial Security
FS1100. These next questions are about the food eaten in your household in the last 12 months, and whether you were
able to afford the food you need.
FS1200. Which of these statements best describes the food eaten in your household in the last 12 months:
Enough of the kinds of food we want to eat,............................................. 1
Enough, but not always the kinds of food we want,.................................. 2
Sometimes not enough food to eat, or ..................................................... 3
Often not enough food to eat?.................................................................. 4
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
(FS1400)
(FS1400)
(FS1400)
(FS1400)
FS1300. Here are some reasons why people don’t always have enough to eat. For each one, please tell me if this is a
reason why you don’t always have enough to eat.
a.
b.
c.
d.
e.
f.
YES
NO
RF
DK
1
1
1
1
1
1
2
2
2
2
2
2
9--97
9--97
9--97
9--97
9--97
9--97
9--98
9--98
9--98
9--98
9--98
9--98
Not enough money for food?................................................................
Not enough time for shopping or cooking?...........................................
Too hard to get to the store? ................................................................
On a diet? ............................................................................................
No working stove available? ................................................................
Not able to cook or eat because of health problems? ..........................
FS1400. Since {MONTH}, did you receive benefits from the WIC program, that is, the Women, Infants and Children
program?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS1500. Since {MONTH}, did you or any members of your household receive Food Stamps (which includes a food stamp
card or voucher, or cash grants from the state for food)?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS1600. Since {MONTH}, have you or any members of your household received TANF or welfare?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
Appendix A
A.1.4d - 69
Version 1/20/08
Visit Type: 6 Month, 12 Month
Target: Mother
Section: FS; #14, #13
FS1600. Since {MONTH}, have you or any members of your household received TANF or welfare?
YES .......................................................................................................... 1
NO ............................................................................................................ 2
REFUSED .......................................................................................... 9--97
DON'T KNOW .................................................................................... 9--98
FS1700. Thank you for answering these questions. This completes the interview portion of the visit.
Appendix A
A.1.4.e–1
18 Month Maternal Phone Call Subject Areas
Child Care—Update of information collected at the 12-month visit
Medical History (Child)—Doctor visits, hospitalizations, immunizations, diagnoses, medicines,
developmental milestones
Child Temperament/Emotional Regulation—Early Childhood Behavior Questionnaire (ECBQ)
Maternal and Paternal Attachment—Parents’ Socioemotional Investment in Children (PIC)
Scale
Major Life Events—Current household status (addition or subtraction of partner), pregnancy
status
Maternal and Paternal Attachment—Parents’ Socioemotional Investment in Children (PIC)
Scale
Neighborhood—Neighborhood Environment for Children Rating Scales (NECRS)
Occupational Take-Home Exposures—Update of information collected at 12-month visit
In-Home Exposures—Renovations, water damage, laundry practices, pesticide use
Appendix A
A.1.4.f–1
24 Month Maternal Phone Call Subject Areas
Child Care —Update of information collected at the 18-month interview
Medical History (Child)—Doctor visits, hospitalizations, immunizations, diagnoses, medicines,
developmental milestones
Child Autism Screening—The Modified Checklist for Autism in Toddlers (M-CHAT)
Child Socio-Emotional Functioning/Behavior—Bayley Scales of Infant and Toddler
Development: Social subtest of the Adaptive
Behavior Scale
Child Adaptive Behavior—Bayley Scales of Infant and Toddler Development: Self-Care, Leisure,
Health and Safety subtests of the Adaptive Behavior Scale
Major Life Events—Current household status (addition or subtraction of partner), pregnancy
status
In-Home Exposures—Pesticide use
Product Use—Use of traditional or alternative medicines, insect repellent, lice and scabies
treatments, cleaning products, scented products
Parenting Practices and Beliefs—Parenting behaviors and attitudes and activities with child
(books, television, toys, walks, toilet training, etc.)
This page is intentionally blank.
| File Type | application/pdf |
| File Title | REQUEST FOR OMB CLEARANCE |
| Author | Ruth Thomson |
| File Modified | 2008-01-25 |
| File Created | 2008-01-25 |