2.4 Take Home Packet

ATTACHMENT 8 TAKE-HOME PACKET OMB #: 0925-XXXX

EXPIRATION DATE: XX/XX/XXXX

Stress and Cortisol Measurement Substudy

Take-Home Packet

Study ID: _______________________

Please circle the number of the appropriate response or fill in the blank for each question

Current Family Profile

Family Member	Age (Completed Years)	Height (Feet and Inches)	Weight (Pounds)
You
Partner/Husband
Child #1
Child #2
Child #3
Child #4
Child #5
Your Mother
Your Father

Your History

1. What is your birth order?

1…….Oldest

2…….Middle

3…….Youngest

4…….Only Child

2. How old were you/will you be when you gave/give birth to your first child? _______ years old

3. What is the lowest weight you have ever reached as an adult? As an adult, we mean 18 years of age or older. _______ pounds

4. How old were you when you were at your lowest weight? _______ years old

5. How long were you at your lowest weight? _______ years

6. What is the highest weight you have ever reached as an adult? _______ pounds

7. How old were you when you were at your highest weight? _______ years old

8. How long were you at your highest weight? _______ years

9. Excluding pregnancy, has your body weight changed (lost or gained more than 20 pounds) since you became an adult?

1…….Yes (Continue to Q10)

2…….No (Skip to Q11)

10. IF YES: How many times in your adult life has this occurred? _______ times

11. How old were you when you got your first period? _______ years old

12. How much did you weigh the day you found out you were pregnant? _______ pounds

13. Do you know what your own birth weight was?

1…….Yes (Continue to Q14)

2…….No (Skip to Q17)

14. IF YES: What was it? _______ lbs. _______ oz.

15. What is the source of this information? ______________

16. How confident are you about the accuracy of this information?

1……Not at all Confident

2……Somewhat/Moderately Confident

3……Very Confident

Your Mother’s History

17. What was your mother’s birth weight? _______ lbs. _______ oz.

I do not know this information

18. How old was your mother when she got her first period? _______ years old

I do not know this information

19. How old was your mother when she gave birth to her first child? _______ years old

I do not know this information

20. How many times has your mother given birth? Please count multiple births as one birth and also include stillbirths. _______ times

I do not know this information

Questions about Family Background

We are going to ask you about your family’s racial and ethnic backgrounds. Ethnicity and race are two separate issues, so please answer each question independently.

21. HCD018B/(ETHNICITY). Do you consider yourself to be Hispanic, Latino/a or Spanish origin?

INTERVIEWER INSTRUCTIONS:

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

No, not of Hispanic, Latino/a, or Spanish origin 1

Yes, Mexican, Mexican American, Chicano/a 2

Yes, Puerto Rican 3

Yes, Cuban 4

Yes, Another Hispanic, Latino/a, or Spanish origin 5

REFUSED -1

DON’T KNOW -2

22. HCD018C/(RACE). What race do you consider yourself to be? You may select one or more.

INTERVIEWER INSTRUCTIONS:

• IF USING SHOWCARDS, REFER PARTICIPANT TO APPROPRIATE SHOWCARD.

• OTHERWISE, READ RESPONSE CATEGORIES TO PARTICIPANT.

• SELECT ALL THAT APPLY.

• CODE “SOME OTHER RACE” ONLY IF VOLUNTEERED.

• PROBE: Anything else?

WHITE, 1

BLACK OR AFRICAN AMERICAN, 2

AMERICAN INDIAN OR ALASKA NATIVE, 3

ASIAN INDIAN 4

CHINESE 5

FILIPINO 6

JAPANESE 7

KOREAN 8

VIETNAMESE 9

OTHER ASIAN 10

NATIVE HAWAIIAN 11

GUAMANIAN OR CHAMORRO 12

OTHER PACIFIC ISLANDER 13

SAMOAN 14

SOME OTHER RACE -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF RACE = ANY COMBINATION OF 1 THROUGH 15, GO TO PARTICIPANT_SEX.

• IF RACE = ANY COMBINATION OF 1 THROUGH 15 AND -5, GO TO RACE_OTH.

• IF RACE = -5, GO TO RACE_OTH.

• IF RACE = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PARTICIPANT_SEX.

23. HCD018D/(RACE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

24. Was your mother born in the United States?

1…….Yes (Skip to Q26)

2…….No (Continue to Q25)

I do not know this information (Skip to Q26)

25. IF NO: What was your mother’s country of birth? ______________________

I do not know this information

26. DE005/(ETHNICITY). Does your father consider himself to be Hispanic, Latino or Spanish origin?

INTERVIEWER INSTRUCTIONS:

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

No, not of Hispanic, Latino/a, or Spanish origin 1

Yes, Mexican, Mexican American, Chicano/a 2

Yes, Puerto Rican 3

Yes, Cuban 4

Yes, Another Hispanic, Latino/a, or Spanish origin 5

REFUSED -1

DON’T KNOW -2

27. DE006/(RACE). What race does your father consider himself to be? You may select one or more.

INTERVIEWER INSTRUCTIONS:

• IF USING SHOWCARDS, REFER PARTICIPANT TO APPROPRIATE SHOWCARD.

• OTHERWISE, READ RESPONSE CATEGORIES TO PARTICIPANT.

• SELECT ALL THAT APPLY.

• CODE “SOME OTHER RACE” ONLY IF VOLUNTEERED.

• PROBE: Anything else?

WHITE, 1

BLACK OR AFRICAN AMERICAN, 2

AMERICAN INDIAN OR ALASKA NATIVE, 3

ASIAN INDIAN 4

CHINESE 5

FILIPINO 6

JAPANESE 7

KOREAN 8

VIETNAMESE 9

OTHER ASIAN 10

NATIVE HAWAIIAN 11

GUAMANIAN OR CHAMORRO 12

OTHER PACIFIC ISLANDER 13

SAMOAN 14

SOME OTHER RACE -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF RACE = ANY COMBINATION OF 1 THROUGH 15, GO TO PARTICIPANT_SEX.

• IF RACE = ANY COMBINATION OF 1 THROUGH 15 AND -5, GO TO RACE_OTH.

• IF RACE = -5, GO TO RACE_OTH.

• IF RACE = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PARTICIPANT_SEX.

28. HCD018D/(RACE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

29. Was your father born in the United States?

1…….Yes (Skip to Q31)

2…….No (Continue to Q30)

I do not know this information (Skip to Q31)

30. IF NO: What was your father’s country of birth? ______________________

I do not know this information

31. DE005/(ETHNICITY). Does the baby’s paternal grandmother (biological father’s mother) consider herself to be Hispanic, Latina or Spanish origin?

INTERVIEWER INSTRUCTIONS:

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

No, not of Hispanic, Latino/a, or Spanish origin 1

Yes, Mexican, Mexican American, Chicano/a 2

Yes, Puerto Rican 3

Yes, Cuban 4

Yes, Another Hispanic, Latino/a, or Spanish origin 5

REFUSED -1

DON’T KNOW -2

32. DE006/(RACE). What race does the baby’s paternal grandmother (biological father’s mother) consider herself to be? You may select one or more.

INTERVIEWER INSTRUCTIONS:

• IF USING SHOWCARDS, REFER PARTICIPANT TO APPROPRIATE SHOWCARD.

• OTHERWISE, READ RESPONSE CATEGORIES TO PARTICIPANT.

• SELECT ALL THAT APPLY.

• CODE “SOME OTHER RACE” ONLY IF VOLUNTEERED.

• PROBE: Anything else?

WHITE, 1

BLACK OR AFRICAN AMERICAN, 2

AMERICAN INDIAN OR ALASKA NATIVE, 3

ASIAN INDIAN 4

CHINESE 5

FILIPINO 6

JAPANESE 7

KOREAN 8

VIETNAMESE 9

OTHER ASIAN 10

NATIVE HAWAIIAN 11

GUAMANIAN OR CHAMORRO 12

OTHER PACIFIC ISLANDER 13

SAMOAN 14

SOME OTHER RACE -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF RACE = ANY COMBINATION OF 1 THROUGH 15, GO TO PARTICIPANT_SEX.

• IF RACE = ANY COMBINATION OF 1 THROUGH 15 AND -5, GO TO RACE_OTH.

• IF RACE = -5, GO TO RACE_OTH.

• IF RACE = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PARTICIPANT_SEX.

33. HCD018D/(RACE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

34. Was your baby’s paternal grandmother born in the United States?

1…….Yes (Skip to Q36)

2…….No (Continue to Q35)

I do not know this information (Skip to Q36)

35. IF NO: What was your baby’s paternal grandmother’s country of birth? ____________

I do not know this information

36. DE005/(ETHNICITY). Does the baby’s paternal grandfather (biological father’s father) consider himself to be Hispanic or Latino?

INTERVIEWER INSTRUCTIONS:

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

No, not of Hispanic, Latino/a, or Spanish origin 1

Yes, Mexican, Mexican American, Chicano/a 2

Yes, Puerto Rican 3

Yes, Cuban 4

Yes, Another Hispanic, Latino/a, or Spanish origin 5

REFUSED -1

DON’T KNOW -2

37. DE006/(RACE). What race does the baby’s paternal grandfather (biological father’s father) consider himself to be? You may select one or more.

INTERVIEWER INSTRUCTIONS:

• IF USING SHOWCARDS, REFER PARTICIPANT TO APPROPRIATE SHOWCARD.

• OTHERWISE, READ RESPONSE CATEGORIES TO PARTICIPANT.

• SELECT ALL THAT APPLY.

• CODE “SOME OTHER RACE” ONLY IF VOLUNTEERED.

• PROBE: Anything else?

WHITE, 1

BLACK OR AFRICAN AMERICAN, 2

AMERICAN INDIAN OR ALASKA NATIVE, 3

ASIAN INDIAN 4

CHINESE 5

FILIPINO 6

JAPANESE 7

KOREAN 8

VIETNAMESE 9

OTHER ASIAN 10

NATIVE HAWAIIAN 11

GUAMANIAN OR CHAMORRO 12

OTHER PACIFIC ISLANDER 13

SAMOAN 14

SOME OTHER RACE -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF RACE = ANY COMBINATION OF 1 THROUGH 15, GO TO PARTICIPANT_SEX.

• IF RACE = ANY COMBINATION OF 1 THROUGH 15 AND -5, GO TO RACE_OTH.

• IF RACE = -5, GO TO RACE_OTH.

• IF RACE = -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO PARTICIPANT_SEX.

38. HCD018D/(RACE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

39. Was your baby’s paternal grandfather born in the United States?

1…….Yes (Skip to Q41)

2…….No (Continue to Q40)

I do not know this information (Skip to Q41)

40. IF NO: What was your baby’s paternal grandfather’s country of birth? ______________________

I do not know this information

Questions about Your Housing History

To better understand maternal-child health, we are collecting information about the physical context of a pregnant woman’s life. The places you have lived since birth will tell us some information about the physical and social characteristics you have experienced over the course of your life. Please try to fill in the following table with as much detail as you can. List the residences where you have lived since birth through your current address. If you need more space, please feel free to write on the back or attach additional pages.

	Approximate Dates of Residence (month, year)	Address (Street, City, State, Zip Code)
41.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
42.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
43.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
44.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
45.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
46.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
47.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
48.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
49.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y
50.	From: __ __/_ _ _ _ M M Y Y Y Y To: __ __/_ _ _ _ M M Y Y Y Y

Neo Five-Factor Inventory (Costa & McCrae, 1985)

Listed below are statements describing how people sometimes think of themselves. Please read each statement carefully and then indicate the extent to which you feel it applies to you by circling the corresponding number. Remember, there are no “right” or “wrong” answers.

	Statements	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1	I am not a worrier.	1	2	3	4	5
2	I like to have a lot of people around me.	1	2	3	4	5
3	I don't like to waste my time daydreaming.	1	2	3	4	5
4	I try to be courteous to everyone I meet.	1	2	3	4	5
5	I keep my belongings neat and clean.	1	2	3	4	5
6	I often feel inferior to others.	1	2	3	4	5
7	I laugh easily.	1	2	3	4	5
8	Once I find the right way to do something, I stick to it.	1	2	3	4	5
9	I often get into arguments with my family and co-workers	1	2	3	4	5
10	I'm pretty good about pacing myself so as to get things done on time.	1	2	3	4	5
11	When I’m under a great deal of stress, sometimes I feel like I’m going to pieces.	1	2	3	4	5
12	I don't consider myself especially "light-hearted."	1	2	3	4	5
13	I am intrigued by the patterns I find in art and nature.	1	2	3	4	5
14	Some people think I'm selfish and egotistical.	1	2	3	4	5
15	I am not a very methodical person.	1	2	3	4	5
16	I rarely feel lonely or blue.	1	2	3	4	5
17	I really enjoy talking to people.	1	2	3	4	5
18	I believe letting students hear controversial speakers can only confuse and mislead them.	1	2	3	4	5
19	I would rather cooperate with others than compete with them.	1	2	3	4	5
20	I try to perform all the tasks assigned to me conscientiously.	1	2	3	4	5
21	I often feel tense and jittery.	1	2	3	4	5
22	I like to be where the action is.	1	2	3	4	5
23	Poetry has little or no effect on me.	1	2	3	4	5
24	I tend to be cynical and skeptical of others' intentions.	1	2	3	4	5
25	I have a clear set of goals and work toward them in an orderly fashion.	1	2	3	4	5
26	Sometimes I feel completely worthless.	1	2	3	4	5
27	I usually prefer to do things alone.	1	2	3	4	5
28	I often try new and foreign foods.	1	2	3	4	5
29	I believe that most people will take advantage of you if you let them.	1	2	3	4	5
30	I waste a lot of time before settling down to work.	1	2	3	4	5
31	I rarely feel fearful or anxious.	1	2	3	4	5
32	I often feel as if I'm bursting with energy.	1	2	3	4	5
33	I seldom notice the moods or feelings that different environments produce.	1	2	3	4	5
34	Most people I know like me.	1	2	3	4	5
35	I work hard to accomplish my goals.	1	2	3	4	5
36	I often get angry at the way people treat me.	1	2	3	4	5
37	I am a cheerful, high-spirited person.	1	2	3	4	5
38	I believe we should look to our religious authorities for decisions on moral issues.	1	2	3	4	5
39	Some people think of me as cold and calculating.	1	2	3	4	5
40	When I make a commitment, I can always be counted on to follow through.	1	2	3	4	5
41	Too often, when things go wrong, I get discouraged and feel like giving up.	1	2	3	4	5
42	I am not a cheerful optimist.	1	2	3	4	5
43	Sometimes when I am reading poetry or looking at a work of art, I feel a chill or wave of excitement.	1	2	3	4	5
44	I am hard-headed and tough-minded in my attitudes.	1	2	3	4	5
45	Sometimes I'm not as dependable or reliable as I should be.	1	2	3	4	5
46	I am seldom sad or depressed.	1	2	3	4	5
47	My life is fast-paced.	1	2	3	4	5
48	I have little interest in speculating on the nature of the universe or the human condition.	1	2	3	4	5
49	I generally try to be thoughtful and considerate.	1	2	3	4	5
50	I am a productive person who always gets the job done.	1	2	3	4	5
51	I often feel helpless and want someone else to solve my problems.	1	2	3	4	5
52	I am a very active person.	1	2	3	4	5
53	I have a lot of intellectual curiosity.	1	2	3	4	5
54	If I don't like people, I let them know it.	1	2	3	4	5
55	I never seem to be able to get organized.	1	2	3	4	5
56	At times I have been so ashamed I just want to hide.	1	2	3	4	5
57	I would rather go my own way than be a leader of others.	1	2	3	4	5
58	I often enjoy playing with theories or abstract ideas.	1	2	3	4	5
59	If necessary, I am willing to manipulate people to get what I want.	1	2	3	4	5
60	I strive for excellence in everything I do.	1	2	3	4	5

Thank you for taking the time to fill out the Stress and Cortisol Measurement Substudy Take Home Packet. Your responses will help us learn more about how women’s experiences affect pregnancy.

Please mail the take-home packet in the provided, pre-addressed, stamped envelope to the following address:

Kristina Nelson

Northwestern University

750 N. Lake Shore Drive, 10^th Floor

Chicago, IL 60611

If you have questions, feel free to call Kristina at (312) 503-5547.

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.