Form 6.1 Survey
Provider-Based Sampling Feasibility Study for the Vanguard (Pilot) Study and Data Collection Updates for the National Children's Study (NICHD)
Attach A16. Tracing Interview
Tracing Interview (PB, EH, TT-HI, TT-LI, PBS)
OMB: 0925-0593
OMB #: 0925-0593
OMB Expiration Date: 08/31/2014
Tracing Interview, Phase 2f
Tracing Interview
Event: |
PBS Participant Eligibility Screening, Pregnancy Visit 1, Pregnancy Visit 2, Birth (EH, PB, HI), Birth (LI)*, 3-Month*, 6-Month*, 9-Month*, 12-Month*, 18-Month*, 24-Month*, 30-Month*
|
Participant:
Respondent:
|
Parent, Caregiver
Parent, Caregiver
|
Domain:
|
Questionnaire
|
Type of Document: |
Interview
|
Allowable Mode: |
In-person (CAPI), Telephone (CATI)**
|
Allowable Method: |
Interviewer-Administered
|
Recruitment Groups: |
EH, PB, HI, LI, PBS
|
Version: |
x.x
|
Release: |
|
*This instrument is OMB-approved for administration at all events listed. However, the instrument will not be administered at the Birth (LI), 3-Month, 6-Month, 9-Month, 12-Month, 18-Month, 24-month, and 30-Month events until the MDES 3.1 release. (The instrument will be administered at PBS Participant Eligibility Screening, Pregnancy Visit 1, Pregnancy Visit 2, and Birth (EH, PB, HI) for the MDES 3.0 release).
**This instrument is OMB-approved for In-person CAPI and Telephone CATI at this time.
This page intentionally left blank.
Tracing Interview
TABLE OF CONTENTS
GENERAL PROGRAMMER INSTRUCTIONS 1
TRACING INTERVIEW
Tracing Interview
GENERAL PROGRAMMER INSTRUCTIONS:
When programming instruments validate field lengths and types against the MDES to ensure data collection responses do not exceed those of the MDES. Some general item limits used are as follows:
DATA ELEMENT FIELDS |
MAXIMUM CHARACTERS PERMITTED |
PROGRAMMER INSTRUCTIONS |
ADDRESS AND EMAIL FIELDS |
100 |
|
UNIT AND PHONE FIELDS |
10 |
|
_OTH AND COMMENT FIELDS |
255 |
|
FIRST NAME AND LAST NAME |
30 |
|
ALL ID FIELDS |
36 |
|
ZIP CODE |
5 |
|
ZIP CODE LAST FOUR |
4 |
|
CITY |
50 |
|
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.) |
10 |
MM MUST EQUAL 00 TO 12 DDMUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR. |
TIME VARIABLES |
TWO DIGIT HOUR AND TWO DIGIT MINUTE, AM/PM DESIGNATION |
HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59 |
Instrument Guidelines for Participant and Respondent IDs:
Prenatally, the P_ID in the MDES header is that of the participant (e.g. the non-pregnant woman, pregnant woman, or the father).
Postnatally, a Respondent ID will be used in addition to the Participant ID because somebody other than the participant may be completing the interview. For example, the Participant may be the Child and the Respondent may be the Mother, Father, or another Caregiver). Therefore, MDES Version 2.2 contains a R_P_ID (Respondent Participant ID) header field for each post birth instrument. This will allow Study Centers to indicate whether the respondent is somebody other than the participant about whom the questions are being asked.
A Reminder:
All respondents must be consented and have records in the Person, Participant, Participant_Consent and LINK_PERSON_PARTICIPANT tables, which can be preloaded into each instrument. Additionally, in post birth questionnaires where there is the ability to loop through a set of questions for multiple children, it is important to capture and store the correct child P_ID along with the loop information. In the MDES, Variable Label/Definition column, this is indicated as follows: External Identifier: Participant ID for child detail.
(TIME_STAMP_TR_ST) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
TR001. The next set of questions asks about different ways we might be able to keep in touch with you. Please remember that all the information you provide is confidential and will not be provided to anyone outside the National Children’s Study.
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = BIRTH, 3 MONTH, 9 MONTH, 18 MONTH, 24 MONTH, OR 30 MONTH AND MODE = CATI, GO STREET_ADDRESS_VARIABLES.
OTHERWISE, IF EVENT_TYPE = PBS PARTICIPANT ELIGIBILITY SCREENING, PREGNANCY VISIT 1, PREGNANCY VISIT 2, 6 MONTH, 12 MONTH, OR 36 MONTH, OR EVENT TYPE = 3 MONTH, 9 MONTH, 18 MONTH, 24 MONTH, OR 30 MONTH AND MODE = CAPI, GO TO PLAN_MOVE.
TR010/(STREET_ADDRESS_VARIABLES). Let me confirm your street address. I have it as {PARENT/CAREGIVER’S ADDRESS}/{What is your street address?}.
INTERVIEWER INSTRUCTION:
MAKE CORRECTIONS TO ADDRESS AS NEEDED.
PROBE AND ENTER AS MUCH INFORMATION AS PARENT/ CAREGIVER KNOWS.
__________________________________________________
(ADDRESS_1) ADDRESS 1 - STREET/PO BOX
(ADDRESS_2) ADDRESS 2
(UNIT) UNIT
(CITY) CITY
|___|___| |___|___|___|___|___| |___|___|___|___
STATE ZIP CODE ZIP+4
(STATE) (ZIP) (ZIP4)
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF STREET ADDRESS VARIABLES COLLECTED PREVIOUSLY FOR (R_FNAME)(R_MNAME)(R_LNAME) AND VALID STREET ADDRESS PROVIDED, PRELOAD VALID STREET ADDRESS FROM MOST RECENT INTERVIEW AND DISPLAY “Let me confirm your street address. I have it as {PARENT/CAREGIVER’S ADDRESS}”.
OTHERWISE, IF STREET ADDRESS VARIABLES NOT COLLECTED PREVIOUSLY FOR (R_FNAME)(R_MNAME)(R_LNAME) OR VALID STREET ADDRESS IS NOT AVAILABLE, DISPLAY “What is your street address?”.
ALLOW INTERVIEWER TO MAKE CORRECTIONS OR ADD NEW ADDRESS INFORMATION.
TR020/(PLAN_MOVE). Do you plan on moving from your present address in the next few months?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF PLAN_MOVE = 1, GO TO WHERE_MOVE.
OTHERWISE, IF PLAN_MOVE = 2, -1, OR -2, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING DATE_MOVE.
TR030/(WHERE_MOVE). Do you know where you will be moving?
YES 1
NO 2 (WHEN_MOVE)
REFUSED -1 (WHEN_MOVE)
DON’T KNOW -2 (WHEN_MOVE)
TR040/(MOVE_INFO). What is the address of your new home?
ADDRESS KNOWN 1
OUT OF THE COUNTRY 2 (WHEN_MOVE)
PO BOX ADDRESS ONLY 3
REFUSED -1 (WHEN_MOVE)
DON’T KNOW -2 (WHEN_MOVE)
TR050/(NEW_ADDRESS_ID). ENTER ADDRESS
INTERVIEWER INSTRUCTION:
PROBE AND ENTER AS MUCH INFORMATION AS PARTICIPANT/PARENT/CAREGIVER KNOWS.
(NEW_ADDRESS1) ADDRESS 1 - STREET/PO BOX
(NEW_ADDRESS2) ADDRESS 2
(NEW_UNIT) UNIT
(NEW_CITY) CITY
|___|___| |___|___|___|___|___| |___|___|___|___
STATE ZIP CODE ZIP+4
(NEW_STATE) (NEW_ZIP) (NEW_ZIP4)
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
IF PSU_ELIG_CONFIRM COLLECTED IN PBS PARTICIPANT ELIGIBILITY SCREENING (DURING CURRENT OR PREVIOUS INTERVIEW) AND PSU_ELIG_CONFIRM = -6, AND
IF NEW INFORMATION IS RECORDED IN STREET ADDRESS VARIABLES OR NEW_ADDRESS_ID, UPDATE PSU_ELIG_CONFIRM TO REFLECT THIS INFORMATION.
TR060/(WHEN_MOVE). Do you know when you will be moving?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF WHEN_MOVE = 1, GO TO DATE_MOVE.
OTHERWISE, IF WHEN_MOVE = 2, -1, OR -2, GO TO SECOND BULLET OF PROGRAMMER INSTRUCTIONS FOLLOWING DATE_MOVE.
TR070/(DATE_MOVE). When will you move?
MONTH:
|___|___|
M M
REFUSED -1
DON’T KNOW -2
YEAR:
|___|___|___|___|
Y Y Y Y
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
FORMAT DATE_MOVE AS YYYYMM.
IF HOME_PHONE COLLECTED PREVIOUSLY FOR (R_FNAME)(R_MNAME)(R_LNAME) AND VALID RESPONSE PROVIDED, GO TO HOME_PHONE_CONFIRM.
OTHERWISE, GO TO HOME_PHONE.
TR080/(HOME_PHONE_CONFIRM). Let me confirm your home phone number. I have it as {HOME PHONE NUMBER}. Is this correct?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
NO LONGER HAS A HOME PHONE -7
PROGRAMMER INSTRUCTIONS:
PRELOAD HOME PHONE NUMBER FROM MOST RECENT INTERVIEW FOR (R_FNAME)(R_MNAME)(R_LNAME).
IF HOME_PHONE_CONFIRM = 1, -1, OR -7, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING HOME_PHONE.
OTHERWISE, IF HOME_PHONE_CONFIRM =2 OR -2, GO TO HOME_PHONE.
TR090/(HOME_PHONE). What is your home phone number?
INTERVIEWER INSTRUCTION:
ENTER PHONE NUMBER AND CONFIRM.
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED -1
DON’T KNOW -2
NO HOME PHONE -7
PROGRAMMER INSTRUCTIONS:
IF CELL_PHONE COLLECTED PREVIOUSLY FOR CURRENT (R_FNAME)(R_MNAME)(R_LNAME) AND VALID RESPONSE PROVIDED, GO TO CELL_PHONE_CONFIRM.
OTHERWISE, GO TO CELL_PHONE.
TR100/(CELL_PHONE_CONFIRM). Let me confirm your cell phone number. I have it as {CELL PHONE NUMBER}. Is this correct?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
NO LONGER HAS A CELL PHONE -7
PROGRAMMER INSTRUCTIONS:
PRELOAD CELL PHONE NUMBER FROM MOST RECENT INTERVIEW FOR CURRENT (R_FNAME)(R_MNAME)(R_LNAME).
IF CELL_PHONE_CONFIRM = 1 AND CELL_PHONE_2 COLLECTED PREVIOUSLY AND VALID RESPONSE PROVIDED, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING CELL_PHONE.
IF CELL_PHONE_CONFIRM = -1 OR -7, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING CELL_PHONE_4.
IF CELL_PHONE_CONFIRM = 2 OR -2, GO TO CELL_PHONE.
OTHERWISE, GO TO CELL_PHONE_2.
TR110/(CELL_PHONE). What is your cell phone number?
INTERVIEWER INSTRUCTION:
ENTER PHONE NUMBER AND CONFIRM.
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED -1
DON’T KNOW -2
NO CELL PHONE ...-7
PROGRAMMER INSTRUCTIONS:
IF CELL_PHONE = -1, -2, OR -7, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING CELL_PHONE_4.
IF CELL_PHONE_2 COLLECTED PREVIOUSLY AND VALID RESPONSE PROVIDED, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING CELL_PHONE_2.
OTHERWISE, GO TO CELL_PHONE_2.
TR120/(CELL_PHONE_2). May we use your cell phone to make future study appointments or for appointment reminders?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF CELL_PHONE_3 COLLECTED PREVIOUSLY AND VALID RESPONSE PROVIDED, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING CELL_PHONE_3.
OTHERWISE, GO TO CELL_PHONE_3.
TR130/(CELL_PHONE_3). Do you send and receive text messages on your cell phone?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF CELL_PHONE_3 = 2, -1, OR -2, OR
IF CELL_PHONE_4 COLLECTED PREVIOUSLY AND VALID RESPONSE PROVIDED, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING CELL_PHONE_4.
OTHERWISE, GO TO CELL_PHONE_4.
TR140/(CELL_PHONE_4). May we send text messages to make future study appointments or for appointment reminders?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = BIRTH, PREGNANCY VISIT 1, PREGNANCY VISIT 2, 6 MONTH, OR 12 MONTH:
IF EMAIL COLLECTED PREVIOUSLY AND VALID RESPONSE PROVIDED, GO TO EMAIL_CONFIRM.
OTHERWISE, GO TO EMAIL.
OTHERWISE, IF EVENT_TYPE = PBS PARTICIPANT ELIGIBILITY SCREENING, 3 MONTH, 9 MONTH, 18 MONTH, 24 MONTH, 30 MONTH, OR 36 MONTH, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING EMAIL_QUEST.
TR150/(EMAIL_ CONFIRM). Let me confirm your email address. I have it as {EMAIL ADDRESS}. Is this correct?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
NO LONGER HAS AN EMAIL ACCOUNT -7
PROGRAMMER INSTRUCTIONS:
PRELOAD EMAIL ADDRESS FROM MOST RECENT INTERVIEW FOR CURRENT (R_FNAME)(R_MNAME)(R_LNAME).
IF EMAIL_CONFIRM = 1 AND EMAIL_APPT COLLECTED PREVIOUSLY AND VALID RESPONSE PROVIDED, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING EMAIL_APPT.
IF EMAIL_CONFIRM = -1 OR -7, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING EMAIL_QUEST.
IF EMAIL_CONFIRM = 2 OR -2, GO TO EMAIL.
OTHERWISE, GO TO EMAIL_APPT.
TR160/(EMAIL). What is the best email address to reach you?
ENTER E-MAIL ADDRESS:
REFUSED -1
DON’T KNOW -2
NO EMAIL ACCOUNT -7
PROGRAMMER INSTRUCTIONS:
SHOW EXAMPLE OF VALID EMAIL ADDRESS SUCH AS MARYJANE@EMAIL.COM.
IF EMAIL = -1, -2, OR -7, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING EMAIL_QUEST.
IF EMAIL_APPT COLLECTED PREVIOUSLY AND VALID RESPONSE PROVIDED, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING EMAIL_APPT.
OTHERWISE, GO TO EMAIL_APPT.
TR170/(EMAIL_APPT). May we use your personal email address to make future Study appointments or send appointment reminders?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF EMAIL_APPT = 2, -1, OR -2, OR
IF EMAIL_QUEST COLLECTED PREVIOUSLY AND VALID RESPONSE PROVIDED, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING EMAIL_QUEST.
OTHERWISE, GO TO EMAIL_QUEST.
TR180/(EMAIL_QUEST). May we use your personal email address for questionnaires that you can answer over the internet?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = BIRTH, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING CONTACT_PHONE_3.
IF EVENT_TYPE = PBS PARTICIPANT ELIGIBILITY SCREENING, PREGNANCY VISIT 1, PREGNANCY VISIT 2, 6 MONTH, OR 12 MONTH, AND VALID CONTACT INFORMATION PROVIDED FOR THREE RELATIVES OR FRIENDS PREVIOUSLY FOR (R_FNAME)/(R_MNAME)/(R_LNAME), GO TO COMM_CONTACT.
IF EVENT_TYPE = PBS PARTICIPANT ELIGIBILITY SCREENING, PREGNANCY VISIT 1, PREGNANCY VISIT 2, 6 MONTH, OR 12 MONTH, AND VALID CONTACT INFORMATION NOT PROVIDED PREVIOUSLY FOR THREE RELATIVES OR FRIENDS FOR (R_FNAME)/(R_MNAME)/(R_LNAME), GO TO TR190.
OTHERWISE, IF EVENT_TYPE = 18 MONTH, 24 MONTH, 30 MONTH, OR 36 MONTH, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING PREV_CITIES_ADDRESS.
TR190. Sometimes if people move or change their telephone number we have difficulty reaching them. We would like the name and contact information for a relative who does not live with you but would always know how to reach you. (CONTACT_1)
TR200/(COMM_CONTACT). In the past, we asked for contact information for three relatives or friends not living with you who would know where you could be reached in case we have trouble contacting you. Has that information changed since our last visit?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF COMM_CONTACT = 1, GO TO CONTACT_1.
OTHERWISE, IF COMM_CONTACT = 2, -1, OR -2, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING CONTACT_PHONE_3.
TR210/(CONTACT_1). Could I have the name of a relative not currently living with you who should know where you could be reached in case we have trouble contacting you?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
DOES NOT HAVE ANY RELATIVES -7
PROGRAMMER INSTRUCTIONS:
IF CONTACT_1 = 1, GO TO (CONTACT_FNAME_1)/(CONTACT_LNAME_1).
IF CONTACT_1 = 2, -1, OR -2, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING CONTACT_PHONE_3.
OTHERWISE, IF CONTACT_1 = -7, GO TO CONTACT_FRND.
TR220/(CONTACT_FRND). Could you give me the name and contact information for a friend who does not live with you but would always know how to reach you?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF CONTACT_FRND = 1, GO TO (CONTACT_FNAME_1)/(CONTACT_LNAME_1).
OTHERWISE, IF CONTACT_FRND = 2, -1, OR -2, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING CONTACT_PHONE_3.
TR230/(CONTACT_FNAME_1)/(CONTACT_LNAME_1). What is this person’s name?
INTERVIEWER INSTRUCTIONS:
IF PARTICIPANT/PARENT/CAREGIVER DOES NOT WANT TO PROVIDE NAME OF CONTACT, ASK FOR INITIALS
CONFIRM SPELLING OF FIRST AND LAST NAMES.
_________________________ _________________________
FIRST NAME LAST NAME
REFUSED -1
DON’T KNOW -2
TR240/(CONTACT_RELATE_1). What is [his/her] relationship to you?
MOTHER/FATHER 1 (CONTACT_ADDR_1)
BROTHER/SISTER 2 (CONTACT_ADDR_1)
AUNT/UNCLE 3 (CONTACT_ADDR_1)
GRANDPARENT 4 (CONTACT_ADDR_1)
NEIGHBOR 5 (CONTACT_ADDR_1)
FRIEND 6 (CONTACT_ADDR_1)
OTHER -5
REFUSED -1 (CONTACT_ADDR_1)
DON’T KNOW -2 (CONTACT_ADDR_1)
TR250/(CONTACT_RELATE1_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR260/(CONTACT_ADDR_1). What is [his/her] address?
INTERVIEWER INSTRUCTIONS:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
____________________________________________________
STREET (C_ADDR1_1)/(C_ADDR_2_1)/(C_UNIT_1)
____________________________________________________
CITY (C_CITY_1)
|___|___| |___|___|___|___|___|
STATE ZIP CODE
(C_STATE_1) (C_ZIPCODE_1) (C_ZIP4_1)
REFUSED -1
DON’T KNOW -2
TR270/(CONTACT_PHONE_1). What is [his/her] telephone number?
INTERVIEWER INSTRUCTION:
IF CONTACT HAS NO TELEPHONE, ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS.
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED -1
DON’T KNOW -2
CONTACT HAS NO TELEPHONE -7
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = PBS PARTICIPANT ELIGIBILITY SCREENING AND VALID RESPONSE PROVIDED FOR CONTACT_PHONE_1, GO TO CONTACT_PHONE1_TYPE_1.
OTHERWISE, GO TO (CONTACT_FNAME_2)/
(CONTACT_LNAME_2).
TR271/(CONTACT_PHONE1_TYPE_1). Is that [his/her] home, work, cell, or another phone number?
HOME 1 (CONTACT_OTHER_PH_1)
WORK 2 (CONTACT_OTHER_PH_1)
CELL 3 (CONTACT_OTHER_PH_1)
FRIEND/RELATIVE 4 (CONTACT_OTHER_PH_1)
OTHER -5
REFUSED -1 (CONTACT_OTHER_PH_1)
DON’T KNOW -2 (CONTACT_OTHER_PH_1)
TR272/(CONTACT_PHONE1_TYPE_1_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR273/(CONTACT_OTHER_PH_1). Is there another phone number where [he/she] can be reached?
YES 1
NO 2 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
REFUSED -1 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
DON’T KNOW -2 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
TR274/(CONTACT_PHONE_2_1). What is that phone number?
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED -1 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
DON’T KNOW -2 (CONTACT_FNAME_2)/
(CONTACT_LNAME_2)
TR275/(CONTACT_PHONE2_TYPE_1). Is that [his/her] home, work, cell, or another phone number?
HOME 1 (CONTACT_FNAME2)/(CONTACT_LNAME_2)
WORK 2 (CONTACT_FNAME2)/(CONTACT_LNAME_2)
CELL 3 (CONTACT_FNAME2)/(CONTACT_LNAME_2)
FRIEND/RELATIVE 4 (CONTACT_FNAME2)/(CONTACT_LNAME_2)
OTHER -5
REFUSED -1 (CONTACT_FNAME2)/(CONTACT_LNAME_2)
DON’T KNOW -2 (CONTACT_FNAME2)/(CONTACT_LNAME_2)
TR276/(CONTACT_PHONE2_TYPE_1_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR280/(CONTACT_FNAME_2) (CONTACT_LNAME_2). Now I’d like to collect information on a second contact who does not currently live with you. What is this person’s name?
INTERVIEWER INSTRUCTIONS:
IF PARTICIPANT/PARENT/CAREGIVER DOES NOT WANT TO PROVIDE NAME OF CONTACT, ASK FOR INITIALS.
CONFIRM SPELLING OF FIRST AND LAST NAMES.
______________ __________________
FIRST NAME LAST NAME
REFUSED -1
DON’T KNOW -2
NO SECOND CONTACT PROVIDED -7
PROGRAMMER INSTRUCTIONS:
IF VALID RESPONSE PROVIDED FOR (CONTACT_FNAME_2)/(CONTACT_LNAME_2), GO TO CONTACT_RELATE_2.
OTHERWISE, IF (CONTACT_FNAME_2)/(CONTACT_LNAME_2) = -1, -2, OR -7, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING CONTACT_PHONE_3.
TR290/(CONTACT_RELATE_2). What is [his/her] relationship to you?
MOTHER/FATHER 1 (CONTACT_ADDR_2)
BROTHER/SISTER 2 (CONTACT_ADDR_2)
AUNT/UNCLE 3 (CONTACT_ADDR_2)
GRANDPARENT 4 (CONTACT_ADDR_2)
NEIGHBOR 5 (CONTACT_ADDR_2)
FRIEND 6 (CONTACT_ADDR_2)
OTHER -5
REFUSED -1 (CONTACT_ADDR_2)
DON’T KNOW -2 (CONTACT_ADDR_2)
TR300/(CONTACT_RELATE2_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR310/(CONTACT_ADDR_2). What is [his/her] address?
INTERVIEWER INSTRUCTIONS:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________________________
STREET (C_ADDR1_2)/(C_ADDR_2_2)/(C_UNIT_2)
_____________________________________________________
CITY (C_CITY_2)
|___|___| |___|___|___|___|___|
STATE ZIP CODE
(C_STATE_2) (C_ZIPCODE_2) (C_ZIP4_2)
REFUSED -1
DON’T KNOW -2
TR320/(CONTACT_PHONE_2). What is [his/her] telephone number?
INTERVIEWER INSTRUCTION:
IF CONTACT HAS NO TELEPHONE, ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED -1
DON’T KNOW -2
CONTACT HAS NO TELEPHONE -7
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = PBS PARTICIPANT ELIGIBILITY SCREENING AND VALID RESPONSE PROVIDED FOR CONTACT_PHONE_2, GO TO CONTACT_PHONE1_TYPE_2.
OTHERWISE, GO TO (CONTACT_FNAME_3)/
(CONTACT_LNAME_3).
TR321/(CONTACT_PHONE1_TYPE_2). Is that [his/her] home, work, cell, or another phone number?
HOME 1 (CONTACT_OTHER_PH_2)
WORK 2 (CONTACT_OTHER_PH_2)
CELL 3 (CONTACT_OTHER_PH_2)
FRIEND/RELATIVE 4 (CONTACT_OTHER_PH_2)
OTHER -5
REFUSED -1 (CONTACT_OTHER_PH_2)
DON’T KNOW -2 (CONTACT_OTHER_PH_2)
TR322/(CONTACT_PHONE1_TYPE_2_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR323/(CONTACT_OTHER_PH_2). Is there another phone number where [he/she] can be reached?
YES 1
NO 2 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
REFUSED -1 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
DON’T KNOW -2 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
TR324/(CONTACT_PHONE_2_2). What is that phone number?
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED -1 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
DON’T KNOW -2 (CONTACT_FNAME_3)/
(CONTACT_LNAME_3)
TR325/(CONTACT_PHONE2_TYPE_2). Is that [his/her] home, work, cell, or another phone number?
HOME 1 (CONTACT_FNAME3)/(CONTACT_LNAME_3)
WORK 2 (CONTACT_FNAME3)/(CONTACT_LNAME_3)
CELL 3 (CONTACT_FNAME3)/(CONTACT_LNAME_3)
FRIEND/RELATIVE 4 (CONTACT_FNAME3)/(CONTACT_LNAME_3)
OTHER -5
REFUSED -1 (CONTACT_FNAME3)/(CONTACT_LNAME_3)
DON’T KNOW -2 (CONTACT_FNAME3)/(CONTACT_LNAME_3)
TR326/(CONTACT_PHONE2_TYPE_2_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR330/(CONTACT_FNAME_3)/(CONTACT_LNAME_3). Now I’d like to collect information on a third contact who does not currently live with you. What is this person’s name?
INTERVIEWER INSTRUCTIONS:
IF PARTICIPANT/PARENT/CAREGIVER DOES NOT WANT TO PROVIDE NAME OF CONTACT, ASK FOR INITIALS
CONFIRM SPELLING OF FIRST AND LAST NAMES.
______________ __________________
FIRST NAME LAST NAME
REFUSED -1
DON’T KNOW -2
NO THIRD CONTACT PROVIDED -7
PROGRAMMER INSTRUCTIONS:
IF VALID RESPONSE PROVIDED FOR (CONTACT_FNAME_3)(CONTACT_LNAME_3), GO TO CONTACT_RELATE_3.
OTHERWISE, IF (CONTACT_FNAME_3)/(CONTACT_LNAME_3) = -1, -2, OR -7, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING CONTACT_PHONE_3.
TR340/(CONTACT_RELATE_3). What is [his/her] relationship to you?
MOTHER/FATHER 1 (CONTACT_ADDR_3)
BROTHER/SISTER 2 (CONTACT_ADDR_3)
AUNT/UNCLE 3 (CONTACT_ADDR_3)
GRANDPARENT 4 (CONTACT_ADDR_3)
NEIGHBOR 5 (CONTACT_ADDR_3)
FRIEND 6 (CONTACT_ADDR_3)
OTHER -5
REFUSED -1 (CONTACT_ADDR_3)
DON’T KNOW -2 (CONTACT_ADDR_3)
TR350/(CONTACT_RELATE3_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR360/(CONTACT_ADDR_3). What is [his/her] address?
INTERVIEWER INSTRUCTIONS:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________________________
STREET (C_ADDR1_3)/(C_ADDR_2_3)/(C_UNIT_3)
_____________________________________________________
CITY (C_CITY_3)
|___|___| |___|___|___|___|___|
STATE ZIP CODE
(C_STATE_3) (C_ZIPCODE_3) (C_ZIP4_3)
REFUSED -1
DON’T KNOW -2
TR370/(CONTACT_PHONE_3). What is [his/her] telephone number?
INTERVIEWER INSTRUCTION:
IF CONTACT HAS NO TELEPHONE, ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED -1
DON’T KNOW -2
CONTACT HAS NO TELEPHONE -7
PROGRAMMER INSTRUCTIONS:
IF EVENT_TYPE = PREGNANCY VISIT 1 AND PRE-PREGNANCY VISIT NOT SET TO COMPLETE, OR
IF EVENT_TYPE = BIRTH AND PRE-PREGNANCY VISIT AND PREGNANCY VISIT 1 NOT SET TO COMPLETE,
GO TO PREV_CITY.
IF EVENT_TYPE = PBS PARTICIPANT ELIGIBILITY SCREENING AND VALID RESPONSE PROVIDED FOR CONTACT_PHONE_3, GO TO CONTACT_PHONE1_TYPE_3.
OTHERWISE, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING PREV_CITIES_ADDRESS.
TR371/(CONTACT_PHONE1_TYPE_3). Is that [his/her] home, work, cell, or another phone number?
HOME 1 (CONTACT_OTHER_PH_3)
WORK 2 (CONTACT_OTHER_PH_3)
CELL 3 (CONTACT_OTHER_PH_3)
FRIEND/RELATIVE 4 (CONTACT_OTHER_PH_3)
OTHER -5
REFUSED -1 (CONTACT_OTHER_PH_3)
DON’T KNOW -2 (CONTACT_OTHER_PH_3)
TR372/(CONTACT_PHONE1_TYPE_3_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
TR373/(CONTACT_OTHER_PH_3). Is there another phone number where [he/she] can be reached?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF CONTACT_OTHER_PH_3 = 1, GO TO CONTACT_PHONE_2_3.
OTHERWISE, IF CONTACT_OTHER_PH_3 = 2, -1, OR -2, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING PREV_CITIES_ADDRESS.
TR374/(CONTACT_PHONE_2_3). What is that phone number?
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF VALID RESPONSE PROVIDED FOR CONTACT_PHONE_2_3, GO TO CONTACT_PHONE2_TYPE_3.
OTHERWISE, IF CONTACT_PHONE_2_3 = -1 OR -2, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING PREV_CITIES_ADDRESS.
TR375/(CONTACT_PHONE2_TYPE_3). Is that [his/her] home, work, cell, or another phone number?
HOME 1
WORK 2
CELL 3
FRIEND/RELATIVE 4
OTHER -5
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
IF CONTACT_PHONE2_TYPE_3 = 1, 2, 3, 4, -1, OR -2, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING PREV_CITIES_ADDRESS.
OTHERWISE, IF CONTACT_PHONE2_TYPE_3 = -5, GO TO CONTACT_PHONE2_TYPE_3_OTH.
TR376/(CONTACT_PHONE2_TYPE_3_OTH).
SPECIFY _____________________________
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTION:
GO TO PROGRAMMER INSTRUCTIONS FOLLOWING PREV_CITIES_ADDRESS.
TR380/(PREV_CITY). In the past three years have you lived in any city or town other than {CITY}?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTUCTIONS:
PRELOAD CITY FROM MOST RECENT INTERVIEW FOR (R_FNAME)(R_MNAME)(R_LNAME).
IF PREV_CITY = 1, GO TO (PREV_CITIES_ADDRESS).
OTHERWISE, IF PREV_CITY = 2, -1, OR -2, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING PREV_CITIES_ADDRESS.
TR390/(PREV_CITIES_ADDRESS). In what cities or towns did you live?
INTERVIEW INSTRUCTION:
RECORD THE THREE MOST RECENT CITIES/TOWNS AND STATES IN WHICH PARTICIPANT HAS LIVED.
_______________________ _______________________
PREVIOUS CITY 1 PREVIOUS STATE 1
(CITY_PREV1) (STATE_PREV1)
_______________________ _______________________
PREVIOUS CITY 2 PREVIOUS STATE 2
(CITY_PREV2) (STATE_PREV2)
_______________________ _______________________
PREVIOUS CITY 3 PREVIOUS STATE 3
(CITY_PREV3) (STATE_PREV3)
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
DO NOT ALLOW CITY_PREV2 OR STATE_PREV2 TO BE FILLED UNLESS CITY_PREV1 AND/OR STATE_PREV1 FILLED.
DO NOT ALLOW CITY_PREV3 OR STATE_PREV3 TO BE FILLED UNLESS CITY_PREV2 AND STATE_PREV2 FILLED.
IF (DR_LICENSE_STATE)/ (DR_LICENSE_NUM) SET TO COMPLETE FOR (R_FNAME)(R_MNAME)(R_LNAME), GO TO SAT_COMMENTS.
IF (DR_LICENSE_STATE)/ (DR_LICENSE_NUM) NOT SET TO COMPLETE FOR CURRENT (R_FNAME)(R_MNAME)(R_LNAME), GO TO (DR_LICENSE_STATE)/(DR_LICENSE_NUM).
TR400/(DR_LICENSE_STATE)/(DR_LICENSE_NUM). What is your driver’s license number? Again, this will only be used to help us stay in touch with you if you move.
INTERVIEWER INSTRUCTION:
RECORD STATE AND LICENSE NUMBER FOR PARTICIPANT.
|___|___|
STATE
|___|___|___|___|___|___|___|___|___|___|___|___|___|
LICENSE NUMBER
REFUSED -1
DON’T KNOW -2
PARTICIPANT DOES NOT HAVE A DRIVER’S LICENSE -7
PROGRAMMER INSTRUCTIONS:
DISPLAY EXAMPLE OF VALID LICENSE NUMBER FOR STATE ENTERED.
DISPLAY APPROPRIATE NUMBER OF ALPHA AND NUMERIC VALUES FOR LICENSE NUMBER PER LICENSE FORMAT FOR STATE ENTERED.
DISPLAY HARD EDIT ERROR IF INTERVIEWER ATTEMPTS TO ENTER VALUE OUTSIDE LICENSE FORMAT FOR STATE ENTERED (E.G., FOR MARYLAND, FORMAT SHOULD BE 1 ALPHA FOLLOWED BY 12 NUMERIC).
TR410/(SAT_COMMENTS). Is there anything else you would like to tell us about {your child or} your experience with the NCS?
YES 1
NO 2 (TIME_STAMP_TR_ET)
REFUSED -1 (TIME_STAMP_TR_ET)
DON’T KNOW -2 (TIME_STAMP_TR_ET)
PROGRAMMER INSTRUCTION:
IF EVENT_TYPE = BIRTH, 3-MONTH, 6-MONTH, 9-MONTH, 12-MONTH, 18-MONTH, 24-MONTH, OR 30-MONTH, DISPLAY “your child or”.
TR420/(SAT_COMMENTS_OTH). SPECIFY
_____________________________________________
REFUSED -1
DON’T KNOW -2
(TIME_STAMP_TR_ET) PROGRAMMER INSTRUCTION:
INSERT DATE/TIME STAMP
END INTERVIEW AND THANK RESPONDENT/PARTICIPANT FOR THEIR TIME.
Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |
© 2024 OMB.report | Privacy Policy