2.3 Visit 1 Stress Questionnaire

ATTACHMENT 7 VISIT 1 STRESS QUESTIONNAIRE OMB #: 0925-XXXX

EXPIRATION DATE: XX/XX/XXXX

STUDY ID NUMBER: __________

DATE OF INTERVIEW: __________

INTERVIEWER’S INITIALS: __________

DATE OF DATA ENTRY: __________

Stress and Cortisol Measurement Substudy

Visit 1 Stress Survey

1. Self-Esteem, Mastery, Optimism (Rosenberg, 1965)

I am going to read a number of statements that people sometimes use to describe themselves, or the way they think about themselves. After I read each statement to you, please select the number that best describes the extent to which you disagree or agree with each item. Please turn to Card 1 of the Stress Survey Response Cards.

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	Do Not Know/ Refused
I feel that I’m a person of worth, at least on an equal basis with others.	1	2	3	4	5
All in all, I am inclined to feel that I’m a failure.	1	2	3	4	5
At times I think I am no good at all.	1	2	3	4	5
I take a positive attitude toward myself.	1	2	3	4	5
On the whole, I am satisfied with myself.	1	2	3	4	5
What happens to me in the future mostly depends on me.	1	2	3	4	5
In uncertain times, I usually expect the best.	1	2	3	4	5
I have very little control over the things that happen to me.	1	2	3	4	5
If something can go wrong for me, it will.	1	2	3	4	5
I’m always optimistic about my future.	1	2	3	4	5
I hardly ever expect things to go my way.	1	2	3	4	5
Things never work out the way I want them to.	1	2	3	4	5
There is really no way I can solve some of the problems I have.	1	2	3	4	5
There is little I can do to change many of the important things in my life.	1	2	3	4	5
I often feel helpless in dealing with the problems of life.	1	2	3	4	5
I can do just about anything I really set my mind to do.	1	2	3	4	5
Sometimes I feel that I’m being pushed around in life.	1	2	3	4	5
I rarely count on good things happening to me.	1	2	3	4	5
I feel that I have a number of good qualities.	1	2	3	4	5

2. Social Support Questionnaire (SSQ) Short-Form (Sherbourne & Stewart, 1991)

Now I am going to ask you about the various kinds of support, or help from others, that is available to you. For this section, please think about the time since you became pregnant.

	Number	Do Not Know/Refused
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.
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?

People sometimes look to others for companionship, assistance, or other types of support. Please tell me how often 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. Please turn to Card 2.

	Rarely or None of the Time	A Little of the Time	Some of the Time	Most of the Time	All of the Time	Do Not Know/ Refused
Someone to help you if you were confined to bed.	1	2	3	4	5
Someone you could count on to listen to you when you need to talk.	1	2	3	4	5
Someone to give you good advice about a crisis.	1	2	3	4	5
Someone to take you to the doctor if you needed it.	1	2	3	4	5
Someone who shows you love and affection.	1	2	3	4	5
Someone to have a good time with.	1	2	3	4	5
Someone to give you information to help you understand a situation.	1	2	3	4	5
Someone to confide in or talk to about yourself or your problems.	1	2	3	4	5
Someone to get together with for relaxation.	1	2	3	4	5
Someone to prepare your meals if you were unable to do it yourself.	1	2	3	4	5
Someone whose advice you really want.	1	2	3	4	5
Someone to do things with, to help you get your mind off things.	1	2	3	4	5
Someone to help with daily chores if you were sick.	1	2	3	4	5
Someone to share your most private worries and fears with.	1	2	3	4	5
Someone to turn to for suggestions about how to deal with a personal problem.	1	2	3	4	5
Someone to do something enjoyable with.	1	2	3	4	5
Someone who understands your problems.	1	2	3	4	5
Someone to love and make you feel wanted.	1	2	3	4	5

3. Social Problems Questionnaire (Corney, 1985)

In this section, I will ask you some questions about general issues related to your current housing, work, finances, social contacts, and domestic life. Please turn to Card 3 and select the most appropriate answer for each question.

1. Are your housing conditions adequate for you and your family’s needs?

1…….Adequate

2…….Slightly Inadequate

3…….Moderately Inadequate

4…….Severely Inadequate

Do not know/Refused

Please turn to Card 4.

2. How satisfied are you with your present accommodations?

1…….Satisfied

2…….Slightly Dissatisfied

3…….Moderately Dissatisfied

4…….Severely Dissatisfied

Do not know/Refused

3. Are you working outside the home?

1……..Yes (Skip to Q5)

2……..No (Continue to Q4)

Do not know/Refused

4. How satisfied are you with this situation?

1……Satisfied

2……Slightly Dissatisfied

3……Moderately Dissatisfied

4……Severely Dissatisfied

Do not know/Refused

(AFTER PARTICIPANT ANSWERS Q4, SKIP TO Q7)

5. How satisfied are you with your present job?

1…….Satisfied

2…….Slightly Dissatisfied

3…….Moderately Dissatisfied

4…….Severely Dissatisfied

Do not know/Refused

Please turn to Card 5.

6. Do you have problems getting along with any people at work?

1……None

2……Slight Problems

3……Many Problems

4……Severe Problems

Do not know/Refused

Please turn to Card 6.

7. Is the money coming in adequate for you and your family’s needs?

1……Adequate

2……Slightly Inadequate

3……Moderately Inadequate

4……Severely Inadequate

Do not know/Refused

Please turn to Card 7.

8. Do you have any difficulties in meeting bills or other financial commitments?

1……None

2……Slight Difficulties

3……Many Difficulties

4……Severe Difficulties

Do not know/Refused

Please turn to Card 8.

9. How satisfied are you with your financial position?

1……Satisfied

2……Slightly Dissatisfied

3……Moderately Dissatisfied

4……Severely Dissatisfied

Do not know/Refused

10. How satisfied are you with the amount of time you are able to go out?

1……Satisfied

2……Slightly Dissatisfied

3……Moderately Dissatisfied

4……Severely Dissatisfied

Do not know/Refused

Please turn to Card 9.

11. Do you have any problems with your neighbors?

1……None

2……Slight Difficulties

3……Many Difficulties

4……Severe Difficulties

Do not know/Refused

12. Do you have any problems getting along with your friends?

1……None

2……Slight Difficulties

3……Many Difficulties

4……Severe Difficulties

Do not know/Refused

Please turn to Card 10.

13. How satisfied are you with the amount of time you see your friends?

1……Satisfied

2……Slightly Dissatisfied

3……Moderately Dissatisfied

4……Severely Dissatisfied

Do not know/Refused

Please turn to Card 11.

14. Do you have any difficulties getting along with close relatives?

1……None

2……Slight Difficulties

3……Many Difficulties

4……Severe Difficulties

Do not know/Refused

Please turn to Card 12.

15. How satisfied are you with the amount of time you spend with your relatives?

1……Satisfied

2……Slightly Dissatisfied

3……Moderately Dissatisfied

4……Severely Dissatisfied

Do not know/Refused

16. Are you married or living as married?

1…….Yes (Continue to Q17)

2…….No (Skip to Q22)

Do not know/Refused

Please turn to Card 13.

17. Do you have difficulties confiding in your partner?

1…..None

2…..Slight Difficulties

3…..Many Difficulties

4…..Severe Difficulties

Do not know/Refused

Please turn to Card 14.

18. Are there any sexual problems in the relationship?

1……None

2……Slight Problems

3……Many Problems

4……Severe Problems

Do not know/Refused

19. Do you have any other problems getting along?

1……None

2……Slight Problems

3……Many Problems

4……Severe Problems

Do not know/Refused

Please turn to Card 15.

20. In general, how satisfied are you with your relationship?

1……Satisfied

2……Slightly Dissatisfied

3……Moderately Dissatisfied

4…....Severely Dissatisfied

Do not know/Refused

Please turn to Card 16.

22. Have you recently been so dissatisfied that you are considering separating from your partner?

1…..No

2…..Sometimes

3…..Often

4…..Yes

Do not know/Refused

23. Do you have children living with you?

1……Yes (Continue to Q23)

2……No (Skip to Q26)

Do not know/Refused

Please turn to Card 17.

24. Do you have difficulties coping with your children?

1……None

2……Slight Difficulties

3……Many Difficulties

4……Severe Difficulties

Do not know/Refused

Please turn to Card 18.

25. How satisfied do you feel with your relationship with your children?

1……Satisfied

2……Slightly Dissatisfied

3……Moderately Dissatisfied

4…....Severely Dissatisfied

Do not know/Refused

Please turn to Card 19.

26. Are there any problems involving your children at school?

1……None

2……Slight Problems

3……Many Problems

4……Severe Problems

Do not know/Refused

	Do you have other adults living with you? 1…..Yes (Continue to Q27) 2…..No (Skip to Q30) Do not know/Refused
	Do you have any problems sharing household tasks? 1……None 2……Slight Problems 3……Many Problems 4……Severe Problems Do not know/Refused Please turn to Card 20.
	Do you have any difficulties with other adults in your household? 1…..None 2…..Slight Difficulties 3…..Moderate Difficulties 4…..Severe Difficulties Do not know/Refused Please turn to Card 21. How satisfied are you with this arrangement? 1……Satisfied 2……Slightly Dissatisfied 3……Moderately Dissatisfied 4……Severely Dissatisfied Do not know/Refused Please turn to Card 22.
	Do you have any legal problems? 1……None 2……Slight Problems 3……Many Problems 4……Severe Problems Do not know/Refused
Do you have any other social problems? 1……None 2……Slight Problems 3……Many Problems 4……Severe Problems Do not know/Refused IF YES: Please indicate the problem(s). The Prenatal Distress Questionnaire (Yali & Lobel, 1999)

To some women, certain aspects of pregnancy are uncomfortable or upsetting, although other women may not be bothered by the same things. Please indicate your own feelings about each statement. Please turn to Card 23.

	Not at All	A Little	Moderately	Very Much	Extremely	Do Not Know/ Refused
I find weight gain during pregnancy troubling.	1	2	3	4	5
Physical symptoms of pregnancy such as nausea, vomiting, swollen feet, or backaches irritate me.	1	2	3	4	5
I am worried about handling the baby when I first come home from the hospital.	1	2	3	4	5
Emotional ups and downs during pregnancy annoy me.	1	2	3	4	5
I am troubled that my relationships with other people important to me are changing due to my pregnancy.	1	2	3	4	5
I am worried about eating healthy food and a balanced diet for the baby.	1	2	3	4	5
Overall, the changes in my body shape and size during pregnancy bother me.	1	2	3	4	5
I am concerned that having a new baby will alter my relationship with the baby's father.	1	2	3	4	5
I worry about having an unhealthy baby.	1	2	3	4	5
I am anxious about labor and delivery.	1	2	3	4	5
The possibility of premature delivery frightens me.	1	2	3	4	5
I am worried that I might not become emotionally attached to the baby.	1	2	3	4	5

4. CES-D Scale (Radloff, 1977)

I am going to read a list of the ways you might feel. For each description that I read to you, please tell me how often you have felt this way during the past 2 weeks—the past 14 days. Please turn to Card 24.

	Rarely or None of the Time	Some or a Little of the Time	Occasionally or a Moderate Amount of the Time	Most or All of the Time	Do Not Know/ Refused
I was bothered by things that usually don’t bother me.	1	2	3	4
I did not feel like eating; my appetite was poor.	1	2	3	4
I felt that I could not shake off the blues even with help from my family or friends.	1	2	3	4
I felt that I was just as good as other people.	1	2	3	4
I had trouble keeping my mind on what I was doing.	1	2	3	4
I felt depressed.	1	2	3	4
I felt that everything I did was an effort.	1	2	3	4
I felt hopeful about the future.	1	2	3	4
I thought my life had been a failure.	1	2	3	4
I felt fearful.	1	2	3	4
My sleep was restless.	1	2	3	4
I was happy.	1	2	3	4
I talked less than usual.	1	2	3	4
I felt lonely.	1	2	3	4
People were unfriendly.	1	2	3	4
I enjoyed life.	1	2	3	4
I had crying spells.	1	2	3	4
I felt sad.	1	2	3	4
I felt that people dislike me.	1	2	3	4
I could not get “going.”	1	2	3	4

5. Perceived Stress Scale (Cohen, 1983)

Now I am going to ask about your feelings or thoughts regarding problems or difficulties that may have occurred during the past month. In each case, you will be asked to indicate how often you felt or thought a certain way. Please turn to Card 25.

During the past month…	Never	Almost Never	Sometimes	Fairly Often	Very Often	Do Not Know/ Refused
How often have you been upset because of something that happened unexpectedly?	1	2	3	4	5
How often have you felt that you were unable to control the important things in your life?	1	2	3	4	5
How often have you felt nervous or “stressed?”	1	2	3	4	5
How often have you felt confident about your ability to handle your personal problems?	1	2	3	4	5
How often have you felt that things were going your way?	1	2	3	4	5
How often have you found that you could not cope with all the things that you had to?	1	2	3	4	5
How often have you been able to control irritations in your life?	1	2	3	4	5
How often have you felt that you were on top of things?	1	2	3	4	5
How often have you been angered because of things that were outside of your control?	1	2	3	4	5
How often have you felt difficulties were piling up so high that you could not overcome them?	1	2	3	4	5

6. Sleep Quality Index (Buysse, 1989))

The following questions relate to your usual sleep habits during the past month only. Your answers should describe your average sleep habits for the days and nights of the past month.

1. When have you usually gone to bed? __________________________

Do not know/Refused

2. How long (in minutes) has it taken you to fall asleep each night? __________________________

Do not know/Refused

3. When have you usually gotten up in the morning? _________________________

Do not know/Refused

4. How many hours of actual sleep did you usually get? (This may be different than the number of hours you spent in bed) _______________________

Do not know/Refused

Please turn to Card 26. During the past month, how often have you had trouble sleeping because you…

	Not During Past Month	Less than Once a Week	Once or Twice a Week	Three or More Times a Week	Do Not Know/ Refused
5. Cannot get to sleep within 30 minutes.	1	2	3	4
6. Wake up in the middle of the night or early morning.	1	2	3	4
Have to get up to use the bathroom.	1	2	3	4
Cannot breathe comfortably.	1	2	3	4
Cough or snore loudly.	1	2	3	4
Feel too cold.	1	2	3	4
Feel too hot.	1	2	3	4
Have bad dreams.	1	2	3	4
Have pain.	1	2	3	4
Other reason(s):	1	2	3	4
During the past month, how often have you taken medicine (prescribed or “over the counter”) to help you sleep?	1	2	3	4
During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?	1	2	3	4
During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done?	1	2	3	4

Please turn to Card 27.

	Very Good	Fairly Good	Fairly Bad	Very Bad	Do Not Know/ Refused
During the past month, how would you rate your sleep quality overall?	1	2	3	4

7. Questions about Your Childhood

This set of questions asks you about certain things related to your childhood and your family’s resources when you were a child. By childhood, we mean age 16 and younger. Please turn to Card 28.

1. When you were growing up, did you get regular medical check-ups?

1…….Yes

2…….No

Do not know/Refused

Please turn to Card 29.

2. When you were growing up, was your family able to obtain medical services when needed?

1…….Yes, Always
2…….Yes, Usually
3…….Yes, Sometimes
4…….Rarely or Never Do not know/Refused

Please turn to Card 30.

3. How would you rate the quality of the medical services you received while growing up, taking into account the competency of the providers and the convenience of the facilities and services?

1…….Poor 2......Fair
3…….Good
4…….Excellent Do not know/Refused

Please turn to Card 31.

4. Did your family ever receive any form of public assistance, such as food stamps, AFDC (Aid to Families with Dependent Children), Medicaid, or SSI (Supplemental Security Income) when you were a child?

1…….Yes

2…….No

Do not know/Refused

5. How many people lived in your household including yourself when you were growing up? ____________________

Do not know/Refused

When you were growing up, did your family…

6. Own a home?

1……. Yes (Continue to Q7)

2……..No (Skip to Q8)

Do not know/Refused

7. IF YES: Did your family own property in addition to your home, such as a vacation or summer home, rental property or commercial real estate?

1……Yes

2……No

Do not know/Refused

8. Own a car?

1…….Yes (Continue to Q9)

2…….No (Skip to Q10)

Do not know/Refused

9. IF YES: Did your family have more than 1 car?

1……Yes

2……No

Do not know/Refused

10. Take regular family vacations?

1…….Yes

2…….No

Do not know/Refused

11. Have a savings account, college fund, or investments?

1……Yes

2……No

Do not know/Refused

12. Have a television?

1……Yes (Continue to Q13)

2……No (Skip to Q14)

Do not know/Refused

13. IF YES: Did your family have more than 1 television?

1……Yes

2……No

Do not know/Refused

14. Have a stereo system?

1…….Yes

2…….No

Do not know/Refused

15. Have a telephone most or all of the time?

1…….Yes (Continue to Q16)

2…….No (Skip to Q17)

Do not know/Refused

16. IF YES: Did your family have more than one telephone line?

1……Yes

2……No

Do not know/Refused

17. Own a washer and dryer?

1…….Yes

2…….No

Do not know/Refused

18. Go out to eat in restaurants often?

1…….Yes

2…….No

Do not know/Refused

As a child, did you.....

19. Attend private schools?

1…….Yes

2…….No

Do not know/Refused

20. Take music, dance, or art lessons?

1…….Yes

2…….No

Do not know/Refused

21. Take classes or lessons in sports, like gymnastics or tennis, outside of school?

1……Yes

2……No

Do not know/Refused

22. As a child, did your family regularly buy new clothes for school or special occasions?

1…….Yes

2…….No

Do not know/Refused

8. Childhood Trauma Questionnaire (Bernstein, 1994)

Please turn to Card 32. Thinking again about your childhood, please answer the following questions. When I was growing up….

When I was growing up…	Never True	Rarely True	Sometimes True	Often True	Very Often True	Do Not Know/ Refused
I didn’t have enough to eat.	1	2	3	4	5
I knew that there was someone to take care of me and protect me.	1	2	3	4	5
People in my family called me things like “stupid,” “lazy,” or “ugly.”	1	2	3	4	5
My parents were too drunk or high to take care of the family.	1	2	3	4	5
There was someone in my family who helped me feel that I was important or special.	1	2	3	4	5
I had to wear dirty clothes.	1	2	3	4	5
I felt loved.	1	2	3	4	5
I thought that my parents wished I had never been born.	1	2	3	4	5
I got hit so hard by someone in my family that I had to see a doctor or go to the hospital.	1	2	3	4	5
There was nothing I wanted to change about my family.	1	2	3	4	5
People in my family hit me so hard that it left me with bruises or marks.	1	2	3	4	5
I was punished with a belt, a board, a cord, or some other hard object.	1	2	3	4	5
People in my family looked out for each other.	1	2	3	4	5
People in my family said hurtful or insulting things to me.	1	2	3	4	5
I believe that I was physically abused.	1	2	3	4	5
I had the perfect childhood.	1	2	3	4	5
I got hit or beaten so badly that it was noticed by someone like a teacher, neighbor, or doctor.	1	2	3	4	5
I felt that someone in my family hated me.	1	2	3	4	5
People in my family felt close to each other.	1	2	3	4	5
Someone tried to touch me in a sexual way, or tried to make me touch them.	1	2	3	4	5
Someone threatened to hurt me or tell lies about me unless I did something sexual with them.	1	2	3	4	5
I had the best family in the world.	1	2	3	4	5
Someone tried to make me do sexual things or watch sexual things.	1	2	3	4	5
Someone molested me.	1	2	3	4	5
I believe that I was emotionally abused.	1	2	3	4	5
There was someone to take me to the doctor if I needed it.	1	2	3	4	5
I believe that I was sexually abused.	1	2	3	4	5
My family was a source of strength and support.	1	2	3	4	5

9. Williams Discrimination Scale (Williams, 1997)

I am now going to ask you some questions about discrimination that you may or may not experience in your day-to-day life. By discrimination, we mean being treated unfairly because of your race, ethnicity, income level, social class, sex, gender, age, sexual orientation, physical appearance, or religion. In your day-to-day life, please indicate how often any of the following things have happened to you as well as the reason you believe they happened. Please turn to Card 33.

FILL IN THE APPROPRIATE REASON CODE INTO THE REASON CODE COLUMN USING THE TABLE BELOW. IF THE PARTICIPANT SAYS, “OTHER,” ENTER THE CODE AND A SHORT DESCRIPTION.

REASON CODES
1	Ethnicity
2	Gender
3	Race
4	Age
5	Religion
6	Physical Appearance
7	Sexual Orientation
8	Income Level/Social Class
9	Other
88	Do Not Know/Refused

	Never	Less than Once a Year	A Few Times a Year	A Few Times a Month	At Least Once a Week	Almost Everyday	Do Not Know/ Refused	Reason Code
You are treated with less courtesy than other people.	1	2	3	4	5	6
You are treated with less respect than other people.	1	2	3	4	5	6
You receive poorer service than other people at restaurants and stores.	1	2	3	4	5	6
People act as if they think you are not smart.	1	2	3	4	5	6
People act as if they are afraid of you.	1	2	3	4	5	6
People act as if they think you are dishonest.	1	2	3	4	5	6
People act as if they are better than you are.	1	2	3	4	5	6
You are called names or insulted.	1	2	3	4	5	6
You are threatened or harassed.	1	2	3	4	5	6

Please turn to Card 34.

10. For unfair reasons, do you think that you have ever not been hired for a job?

1……No (Skip to Q12)

2……Yes (Continue to Q11)

Do not know/Refused

11. What do you think the main reason was for not hiring you?

Reason Code: __________

IF OTHER: Please specify: _____________________________________________________

12. Have you ever been unfairly stopped, searched, questioned, physically threatened, or abused by the police?

1……No

2……Yes

Do not know/Refused

13. What do you think was the main reason the police treated you that way?

Reason Code: __________

IF OTHER: Please specify: _____________________________________________________

10. Abuse Assessment Screen (McFarlane, 1992)

The last set of questions refers to events that may have taken place at any point in your life. Some of these are personal or even uncomfortable, but remember your answers are confidential. Please turn to Card 35.

1. Have you ever been emotionally or physically abused by your partner or someone important to you?

1……Yes

2……No

Do not know/Refused

2. Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?

1…..Yes (Continue to Q3)

2…..No (Skip to Q5)

Do not know/Refused

3. IF YES: By whom? (select all that apply)

1…..Husband

2…..Ex-husband

3…..Partner

4…..Stranger

5…..Other (Specify) _______________

Do not know/Refused

4. How many times did they physically hurt you? _________

Do not know/Refused

5. Since you have been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone?

1……Yes (Continue to Q6)

2……No (Skip to Q10)

Do not know/Refused

6. IF YES: By whom? (select all that apply)

1…..Husband

2…..Ex-husband

3…..Partner

4…..Stranger

5…..Other (Specify) __________

Do not know/Refused

7. How many times did they physically hurt you? _________

Do not know/Refused

8. Can you point to the location on your body where they physically hurt you? ______________

Do not know/Refused

Please turn to Card 36.

9. Please indicate the most severe incident:

1……Threats of abuse, including use of a weapon

2……Slapping, pushing; no injuries and/or lasting pain

3……Punching, kicking, bruises, cuts and/or continuing pain

4……Beaten up, severe contusions, burns, broken bones

5……Head, internal, and/or permanent injury

6……Use of weapon, wound from weapon

Do not know/Refused

Please turn to Card 37.

10. Within the past year, has anyone forced you to do sexual activities?

1……Yes (Continue to Q11)

2……No (Skip to Q13)

Do not know/Refused

11. IF YES: By whom?

1…..Husband

2…..Ex-husband

3…..Partner

4…..Stranger

5…..Others (specify) __________

Do not know/Refused

12. How many times did they force you to do sexual activities? _________

Do not know/Refused

13. Are you afraid of your partner or anyone else?

1…..Yes (Continue to Q14)

2…..No (Skip to next section)

Do not know/Refused

Do you want us to reveal this information to:

14. The obstetricians looking after you?

1….Yes

2….No

Do not know/Refused

15. The medical social worker for further management?

1….Yes

2….No

Do not know/Refused

Thank you so much for completing the Visit 1 Stress Survey! Next I will ask you to provide a hair sample like we discussed earlier, but first I would like to ask you a few questions about your hair.

1. Do you use hair products on a regular basis?

1…….Yes

2…….No

Do not know/Refused

2. Do you use a hair dryer, curling iron, or straightener on a regular basis?

1…….Yes

2…….No

Do not know/Refused

3. Is your hair currently dyed, bleached, or highlighted?

1…….Yes

2…….No

Do not know/Refused

4. Do you currently have a perm or has your hair been professionally straightened?

1…….Yes

2…….No

Do not know/Refused

Public reporting burden for this collection of information is estimated to average one hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.