Form 5.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Pregnancy Visit 2 Interview - Adult, Phase 2g

OMB Specification

Pregnancy Visit 2 Questionnaire - Adult

Event Category:	Trigger-Based
Event:	PV2
Administration:	N/A
Instrument Target:	Pregnant Woman
Instrument Respondent:	Pregnant Woman
Domain:	Questionnaire
Document Category:	Questionnaire
Method:	Data Collector Administered
Mode (for this instrument*):	In-Person, CAI; Phone, CAI
OMB Approved Modes:	In-Person, CAI; Phone, CAI; Web-Based, CAI
Estimated Administration Time:	10 minutes
Multiple Child/Sibling Consideration:	Per Event
Special Considerations:	N/A
Version:	1.0
MDES Release:	4.0

*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

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Pregnancy Visit 2 Questionnaire - Adult

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

CURRENT PREGNANCY INFORMATION 3

BABY'S FATHER IDENTIFICATION 17

EMPLOYMENT 22

SOCIAL SUPPORT 26

HEALTH INSURANCE 29

CLOSING SCRIPTS 32

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Pregnancy Visit 2 Questionnaire - Adult

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	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: 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 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs 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.

CURRENT PREGNANCY INFORMATION

(TIME_STAMP_CPI_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) FOR PREGNANT WOMAN.

• PRELOAD MULTIPLE_GESTATION FROM PREGNANCY VISIT 1 INTERVIEW.

• IF MULTIPLE_GESTATION = 2 OR 3 IN PREGNANCY VISIT 1 INTERVIEW, DISPLAY 
  "babies" AS APPROPRIATE THROUGHOUT INSTRUMENT.

• IF MULTIPLE_GESTATION = 1, -1, OR -2 IN PREGNANCY VISIT 1 INTERVIEW, DISPLAY "baby" APPROPRIATE THROUGHOUT THE INSTRUMENT.

• PRELOAD F_F_NAME, F_L_NAME, CONTACT_F_LATER AND FATHER_KNOW_PREG FROM PREGNANCY VISIT 1 SAQ.

INTERVIEWER INSTRUCTIONS

• MODIFY TRANSITIONAL STATEMENTS AS NEEDED TO MAKE APPROPRIATE FOR CURRENT INTERVIEW.

CPI01000. In the next set of questions, I'll ask about you, your health, and your health history.

CPI02000/(PREGNANT). The first questions ask about how your pregnancy is progressing.  First, are you still pregnant?

Label	Code	Go To
YES	1	CPI05000
NO	2
REFUSED	-1	CS02000
DON'T KNOW	-2	CS02000

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

CPI03000. I'm so sorry for your loss.  I know this can be a difficult time.

INTERVIEWER INSTRUCTIONS

• USE SOCIAL CUES AND PROFESSIONAL JUDGMENT IN RESPONSE.

• IF ROC HAS PREGNANCY LOSS INFORMATION TO DISSEMINATE, OFFER TO PARTICIPANT 

CPI04000/(LOSS_INFO). INTERVIEWER-ANSWERED QUESTION:   DID PARTICIPANT REQUEST ADDITIONAL INFORMATION ON COPING WITH PREGNANCY LOSS?

Label	Code	Go To
YES	1	CS01000
NO	2	CS01000

CPI05000. What is your current due date?

INTERVIEWER INSTRUCTIONS

• IF SOFT EDIT MESSAGE DISPLAYED, ASK QUESTION AGAIN.

SOURCE

Pregnancy, Infection and Nutrition Study

(DUE_DATE_MM) MONTH:

|_____|_____|

     M        M

Label	Code	Go To
REFUSED	-1	BPLAN_CHANGE
DON'T KNOW	-2

(DUE_DATE_DD) DAY:

|_____|_____|

     D        D

Label	Code	Go To
REFUSED	-1	BPLAN_CHANGE
DON'T KNOW	-2

(DUE_DATE_YYYY) YEAR:

|____|____|____|____|

    Y      Y       Y       Y

Label	Code	Go To
REFUSED	-1	BPLAN_CHANGE
DON'T KNOW	-2	BPLAN_CHANGE

PROGRAMMER INSTRUCTIONS

• PERFORM A SOFT EDIT CHECK OF REPORTED DUE DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:

• IF DATE IS MORE THAN 9 MONTHS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: "YOU HAVE ENTERED A DATE THAT IS MORE THAN 9 MONTHS FROM TODAY.  RE-ENTER DATE."

• IF DATE IS MORE THAN 1 MONTH BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION:  "YOU HAVE ENTERED A DATE THAT OCCURRED MORE THAN A MONTH BEFORE TODAY.  RE-ENTER DATE."

• IF DUE_DATE_MM AND DUE_DATE_DD ≠ -1 AND IF DUE_DATE_YYYY ≠ -1 OR -2, GO TO DATE_KNOWN.

CPI06000/(DATE_KNOWN). DID PARTICIPANT GIVE DATE?

Label	Code	Go To
PARTICIPANT GAVE COMPLETE DATE	1
PARTICIPANT GAVE PARTIAL DATE	2

CPI07000/(BPLAN_CHANGE). Has the place where you plan to deliver your {baby/babies} changed since we last spoke with you?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children's Study, Legacy Phase (T1 Mother)

CPI08000/(BIRTH_PLAN). {So we make sure we have the correct information,} Where do you plan to deliver your {baby/babies}?

PROGRAMMER INSTRUCTIONS

• IF BPLAN_CHANGE = 2, DISPLAY "So we make sure we have the correct information,"

Label	Code	Go To
In a hospital	1
A birthing center	2
At home	3	USE_PR_LOG
Some other place	4
REFUSED	-1	USE_PR_LOG
DON"T KNOW	-2	USE_PR_LOG

SOURCE

National Children's Study, Legacy Phase (T1 Mother)

CPI09000. What is the name and address of the place where you are planning to deliver your {baby/babies}?

SOURCE

National Children's Study, Legacy Phase (T1 Mother)

(BIRTH_PLACE) ____________________________________________________________

NAME OF BIRTH HOSPITAL/BIRTHING CENTER

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(B_ADDRESS_1) ____________________________________________________________

STREET ADDRESS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(B_ADDRESS_2) ____________________________________________________________

ADDRESS 2

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(B_CITY) ____________________________________________

CITY

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(B_STATE) |_____|_____|

STATE

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(B_ZIPCODE) |____|____|____|____|____|

ZIP CODE

Label	Code	Go To
REFUSED	-1
DON'T KNOW	0

CPI10000/(USE_PR_LOG). Are you using the Pregnancy Health Care Log?  This is the booklet that you or your health care provider (doctor, midwife, nurse, etc.) uses to record information about your medical visits.

Label	Code	Go To
YES	1	NUM_PROV_PR_LOG
NO	2
REFUSED	-1	CPI17000
DON'T KNOW	-2	CPI17000

SOURCE

National Children's Study, Vanguard Phase (18M, 24M) (modified)

CPI11000/(REASON_NO_PR_LOG). Is that because . . .

INTERVIEWER INSTRUCTIONS

• IF THE PREGNANT WOMAN REPORTS THEY HAVE "misplaced the log," DISTRIBUTE A NEW LOG OR OFFER TO MAIL ONE.

Label	Code	Go To
You haven't had a medical visit since our last interview	1	CPI17000
You've misplaced the log	2	CPI17000
You've forgotten to bring it to your medical visits	3	CPI14000
The log was too much trouble to complete	4	CPI14000
The log was too difficult to understand	5	CPI17000
OTHER	-5
REFUSED	-1	CPI14000
DON'T KNOW	-2	CPI14000

SOURCE

National Children's Study, Vanguard Phase (18M, 24M) (modified)

CPI12000/(REASON_NO_PR_LOG_OTH). SPECIFY:  ___________________________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children's Study, Vanguard Phase (18M, 24M) (modified)

PROGRAMMER INSTRUCTIONS

• GO TO CPI17000.

CPI14000. 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 medical visits.

PROGRAMMER INSTRUCTIONS

• GO TO CPI17000.

CPI15000/(NUM_PROV_PR_LOG). How many health care providers have you seen since using this Pregnancy Health Care Log?

 

|_____|_____|

NUMBER OF PROVIDERS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children's Study, Vanguard Phase (18M, 24M) (modified)

PROGRAMMER INSTRUCTIONS

• IF NUM_PROV_PR_LOG = 0, -1 OR -2, GO TO CPI17000.

• OTHERWISE, GO TO ​NUM_PROV_REC.

CPI16000/(NUM_PROV_REC). Of those providers that you have seen, for how many providers have you recorded contact information such as their address or phone number?

 

|_____|_____|

NUMBER OF CONTACTS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children's Study, Vanguard Phase (18M, 24M) (modified)

CPI17000. I am now going to ask some questions about visits to a doctor or other health care provider, such as a midwife or nurse. You may want to refer to {the Pregnancy Health 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.

PROGRAMMER INSTRUCTIONS

• DISPLAY TEXT IN BRACKETS IN CPI17000 IF USE_PR_LOG = 1.

CPI18000. What was the date of your most recent doctor's visit or checkup since you've become pregnant?

INTERVIEWER INSTRUCTIONS

• SHOW CALENDAR TO ASSIST IN DATE RECALL.

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

SOURCE

National Children's Study, Legacy Phase (T1 Mother, T3 Prior)

(DATE_VISIT_MM) MONTH:

|_____|_____|

    M        M

Label	Code	Go To
HAVE NOT HAD A VISIT	-7
REFUSED	-1
DON'T KNOW	-2

(DATE_VISIT_DD) DATE:

|_____|_____|

     D       D

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(DATE_VISIT_YYYY) YEAR:

|____|____|____|____|

   Y       Y       Y       Y

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

PROGRAMMER INSTRUCTIONS

• IF USE_PR_LOG = 1 AND IF DATE_VISIT_MM, DATE_VISIT_DD, AND DATE_VISIT_YYYY ≠ -1 OR -7, GO TO CPI19000.

• OTHERWISE, GO TO CPI20000.

CPI19000. If you haven't yet done so, please put a check mark in the box next to the visit you just told me about in your Pregnancy Health Care Log.

CPI20000. {At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

PROGRAMMER INSTRUCTIONS

• IF DATE_VISIT_MM, DATE_VISIT_DD, AND DATE_VISIT_YYYY ≠ -7, -1 OR -2, DISPLAY “At this visit or at”.

• OTHERWISE, DISPLAY ‘”At”.

CPI21000/(DIABETES_1). Diabetes?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI22000/(HIGHBP_PREG). High blood pressure?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI23000/(URINE). Protein in your urine?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI24000/(PREECLAMP). Preeclampsia or toxemia?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI25000/(EARLY_LABOR). Early or premature labor?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI26000/(ANEMIA). Anemia or low blood count?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI27000/(NAUSEA). Severe nausea or vomiting, also called hyperemesis?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI28000/(KIDNEY). Bladder or kidney infection?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI29000/(RH_DISEASE). Rh disease or isoimmunization?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI30000/(GROUP_B). Infection with a bacteria called Group B strep?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI31000/(HERPES). Infection with a Herpes virus?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI32000/(VAGINOSIS). Infection of the vagina with bacteria, also called Bacterial vaginosis?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI33000/(OTH_CONDITION). Any other serious condition?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT:  ({At this visit or at/At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED.

Label	Code	Go To
YES	1
NO	2	HOSPITAL
REFUSED	-1	HOSPITAL
DON'T KNOW	-2	HOSPITAL

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI34000/(CONDITION_OTH). SPECIFY:  ____________________________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health and Nutrition Examination Survey (NHANES) (modified)

CPI35000/(HOSPITAL). Since you've been pregnant, have you spent at least one night in the hospital?

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_CPI_ET
REFUSED	-1	TIME_STAMP_CPI_ET
DON'T KNOW	-2	TIME_STAMP_CPI_ET

SOURCE

Pregnancy Risk Assessment Monitoring System

CPI36000. What was the admission date of your most recent hospital stay?

SOURCE

National Children's Study, Legacy Phase (T1 Mother, T3 Prior)

(ADMIN_DATE_MM) MONTH:

|_____|_____|

     M       M

Label	Code	Go To
HAVE NOT BEEN HOSPITALIZED OVERNIGHT/NOT APPLICABLE	-7	TIME_STAMP_CPI_ET
REFUSED	-1
DON'T KNOW	-2

(ADMIN_DATE_DD) DAY:

|_____|_____|

     D       D

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(ADMIN_DATE_YYYY) YEAR:

|____|____|____|____|

    Y       Y       Y      Y

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

CPI37000/(HOSP_NIGHTS). How many nights did you stay in the hospital during this hospital stay?

 

|____|____|____|

NUMBER OF NIGHTS

INTERVIEWER INSTRUCTIONS

• CONFIRM RESPONSE

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

CPI38000/(DIAGNOSE). Did a doctor or other health care provider give you a diagnosis during this hospital stay?

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_CPI_ET
REFUSED	-1	TIME_STAMP_CPI_ET
DON'T KNOW	-2	TIME_STAMP_CPI_ET

SOURCE

National Children's Study, Legacy Phase (T1 Mother, T3 Prior)

CPI39000/(DIAGNOSE_2). What was the diagnosis?

INTERVIEWER INSTRUCTIONS

• PROBE FOR MULTIPLE RESPONSES.

• SELECT ALL THAT APPLY.

Label	Code	Go To
DEHYDRATION	1
PRETERM LABOR	2
HYPEREMESIS	3
PREECLAMPSIA	4
RUPTURE OF MEMBRANES	5
KIDNEY DISORDER	6
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

PROGRAMMER INSTRUCTIONS

• IF DIAGNOSE_2 = ANY COMBINATION OF 1 - 6 AND

• IF USE_PR_LOG = 1, GO TO CPI41000.

• IF USE_PR_LOG = 2, -1, OR -2, GO TO TIME_STAMP_CPI_ET.

• IF DIAGNOSE_2 = -5, OR ANY COMBINATION OF VALUES 1 - 6 AND -5, GO TO DIAGNOSIS_OTH.

• IF DIAGNOSE_2 = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND

• IF USE_PR_LOG = 1, GO TO CPI41000.

• IF USE_PR_LOG - 2, -1, OR -2, TIME_STAMP_CPI_ET.

CPI40000/(DIAGNOSIS_OTH). SPECIFY:  ____________________________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

PROGRAMMER INSTRUCTIONS

• IF USE_PR_LOG = 1, GO TO CPI41000.

• OTHERWISE, GO TO TIME_STAMP_CPI_ET.

CPI41000. 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 Health Care Log.

SOURCE

National Children's Study, Vanguard Phase (18M, 24M)

(TIME_STAMP_CPI_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

BABY'S FATHER IDENTIFICATION

(TIME_STAMP_BFI_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP.

• IF FATHER_KNOW_PREG = 2 AND CONTACT_F_LATER = 1 IN PREGNANCY VISIT 1 SAQ, GO TO BFI01000.

• OTHERWISE, GO TO TIME_STAMP_BFI_ET.

BFI01000. Part of the National Children's Study includes a planned study visit with the baby's father.

PROGRAMMER INSTRUCTIONS

• IF F_F_NAME AND F_L_NAME COLLECTED IN PREGNANCY VISIT 1 SAQ AND ≠ -1 OR -2, GO TO FATHER_NAME_CONFIRM.

• OTHERWISE, IF F_F_NAME AND F_L_NAME NOT COLLECTED IN PREGNANCY VISIT 1 SAQ OR IF = -1 OR -2, GO TO BFI03000.  

BFI02000/(FATHER_NAME_CONFIRM). Just to confirm, is the first name of your baby's father {F_F_NAME}?

Label	Code	Go To
YES	1	FATHER_SAME_HH
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Survey of Child and Adolescent Well-Being Caregiver Interview (NSCAW) (modified); Saving for Education, Entrepreneurship and Down Payment for Oklahoma Kids (SEED) Baseline and Follow-Up Interview; and National Longitudinal Survey of Youth (NLSY).

PROGRAMMER INSTRUCTIONS

• DISPLAY F_F_NAME FROM PV1 SAQ.

• IF FATHER_NAME_CONFIRM = 1,  DISPLAY F_F_NAME THROUGHOUT INSTRUMENT.

• OTHERWISE, DISPLAY "the father of your baby" OR "the father" AS APPROPRIATE THROUGHOUT THE INSTRUMENT.

BFI03000. What is the father's first and last name?

SOURCE

National Survey of Child and Adolescent Well-Being Caregiver Interview (NSCAW) (modified); National Longitudinal Survey of Youth (NLSY) (modified)

(F_F_NAME) ___________________________________________

FIRST NAME 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(F_L_NAME) ___________________________________________

LAST NAME 

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

PROGRAMMER INSTRUCTIONS

• IF F_F_NAME ≠ -1 OR -2,  DISPLAY F_F_NAME THROUGHOUT INSTRUMENT.

• OTHERWISE, DISPLAY "the father of your baby" OR "the father" AS APPROPRIATE THROUGHOUT THE INSTRUMENT.

BFI04000/(FATHER_SAME_HH). Is {F_F_NAME/the father of your baby} living in the same household as you?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Early Childhood Longitudinal Study, Birth Cohort (modified)

BFI05000/(FATHER_KNOW_PREG). Is {F_F_NAME/the father} aware of your pregnancy?

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_BFI_ET
REFUSED	-1	TIME_STAMP_BFI_ET
DON'T KNOW	-2	TIME_STAMP_BFI_ET

SOURCE

National Children's Study, Vanguard Phase (PV1 SAQ)

BFI06000/(CONTACT_F_NOW). May we have your permission to contact {F_F_NAME/the father} and invite him to participate in the Study?

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_BFI_ET
REFUSED	-1	TIME_STAMP_BFI_ET
DON'T KNOW	-2	TIME_STAMP_BFI_ET

SOURCE

National Children's Study, Legacy Phase (T1 Mother)

BFI07000. What is {F_F_NAME/the father}'s home address?

SOURCE

National Children's Study, Vanguard Phase (PV1 SAQ)

(F_ADDR1_2) ____________________________________________________________

ADDRESS 1 - STREET/PO BOX

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(F_ADDR2_2) ____________________________________________________________

ADDRESS 2

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(F_UNIT_2) ____________________________________________

UNIT

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(F_CITY_2) ____________________________________________

CITY

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(F_STATE_2) |_____|_____|

STATE

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(F_ZIPCODE_2) |____|____|____|____|

ZIP CODE

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(F_ZIP4_2) |____|____|____|____|

ZIP4

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

BFI08000/(F_PHONE). What is {F_F_NAME/the father}'s telephone number?

 

|____|____|____|  -  |____|____|____|  -  |____|____|____|____|

INTERVIEWER INSTRUCTIONS

• IF FATHER HAS NO TELEPHONE, ASK FOR TELEPHONE NUMBER WHERE HE RECEIVES CALLS.

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2
FATHER HAS NO TELEPHONE	-7

SOURCE

National Children's Study, Legacy Phase (T1 Mother) (modified)

BFI09000/(F_EMAIL). What is the best email address to reach {F_F_NAME/the father}?

 

_________________________________________________

EMAIL ADDRESS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2
FATHER HAS NO EMAIL ADDRESS	-7

SOURCE

National Children's Study, Legacy Phase (6M)

BFI10000/(F_AGE). What is {F_F_NAME/the father}'s age?

 

|_____|_____|

AGE IN YEARS

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children's Study, Vanguard Phase (PV1 SAQ)

PROGRAMMER INSTRUCTIONS

• IF F_AGE ≥ LOCAL AGE OF MAJORITY, GO TO TIME_STAMP_BFI_ET.

• IF F_AGE < AGE OF MAJORITY, GO TO BFI12000.

• OTHERWISE, IF F_AGE = -1 OR -2, GO TO F_AGE_MAJORITY.

BFI11000/(F_AGE_MAJORITY). Is the father {LOCAL AGE OF MAJORITY} or older?

INTERVIEWER INSTRUCTIONS

• EXPLAIN HOW THE ANSWER TO THIS QUESTION DETERMINES THE FATHER'S ELIGIBILITY AND THAT ALL DATA ARE KEPT CONFIDENTIAL AND SECURE.

Label	Code	Go To
YES	1	TIME_STAMP_BFI_ET
NO	2
REFUSED	-1	TIME_STAMP_BFI_ET
DON'T KNOW	-2	TIME_STAMP_BFI_ET

SOURCE

New

PROGRAMMER INSTRUCTIONS

• PRELOAD LOCAL AGE OF MAJORITY

BFI12000. Because the father is legally considered a minor, we will not contact him to participate in the Study at this time.

(TIME_STAMP_BFI_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

EMPLOYMENT

(TIME_STAMP_EMP_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

EMP01000. Now, I’d like to ask some questions about your current employment status.

EMP02000. The next questions may be similar to those asked the last time we spoke, but we are asking them again because sometimes the answers change. 

EMP03000/(WORK_CURRENTLY). Are you currently employed?

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_EMP_ET
REFUSED	-1	TIME_STAMP_EMP_ET
DON'T KNOW	-2	TIME_STAMP_EMP_ET

SOURCE

Pregnancy, Infection, and Nutrition Study

EMP04000/(HOURS). Approximately how many hours each week are you working? 

 

|_____|_____|_____|

 

NUMBER OF HOURS

PROGRAMMER INSTRUCTIONS

• DISPLAY A SOFT EDIT IF RESPONSE > 60.

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Pregnancy, Infection, and Nutrition Study (modified)

EMP05000/(SHIFT_WORK). Do you currently work a shift that starts after 2 pm? 

Label	Code	Go To
YES	1
NO	2
SOMETIMES	3
REFUSED	-1
DON'T KNOW	-2

SOURCE

Avon Longitudinal Study of Parents and Children (modified)

PROGRAMMER INSTRUCTIONS

• IF WORK_NAME PREVIOUSLY COLLECTED AND ≠ -1 OR -2, GO TO WORK_NAME_CONFIRM.

• IF WORK_NAME NOT PREVIOUSLY COLLECTED OR = -1 OR -2, GO TO WORK_NAME.

EMP06000/(WORK_NAME_CONFIRM). Let me confirm the name of the place where you work.  I have it as {PARTICIPANT’S WORK PLACE NAME}.  Is this correct?

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Evaluation of the Community Health Marriage Incentive and National Longitudinal Survey of Youth (modified)

PROGRAMMER INSTRUCTIONS

• PRELOAD WORK PLACE NAME FROM WORK_NAME IN PREGNANCY VISIT 1 INTERVIEW.

• IF WORK_NAME_CONFIRM = 1, GO TO PROGRAMMER INSTRUCTIONS FOLLOWING WORK_NAME.

• OTHERWISE, IF WORK_NAME_CONFIRM = 2, -1, OR -2, GO TO WORK_NAME.

EMP07000/(WORK_NAME). What is the name of the place where you work?

 

__________________________________________________

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

SOURCE

Evaluation of the Community Health Marriage Incentive and National Longitudinal Survey of Youth (modified)

PROGRAMMER INSTRUCTIONS

• IF WORK_ADDRESS_1, WORK_ADDRESS_2, WORK_UNIT, WORK_CITY, WORK_STATE, WORK_ZIP, AND WORK_ZIP4 NOT COLLECTED PREVIOUSLY OR = -1 OR -2, GO TO EMP09000.

• IF WORK_ADDRESS_1, WORK_ADDRESS_2, WORK_UNIT, WORK_CITY, WORK_STATE, WORK_ZIP, AND ​WORK_ZIP4 COLLECTED PREVIOUSLY AND ≠ -1 OR -2, GO TO WORK_ADDRESS_VARIABLES_CONFIRM. 

EMP08000/(WORK_ADDRESS_VARIABLES_CONFIRM). Let me confirm your work address. I have it as {PARTICIPANT’S WORK ADDRESS}. Is this correct?

Label	Code	Go To
YES	1	TIME_STAMP_EMP_ET
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

Evaluation of the Community Health Marriage Incentive and National Longitudinal Survey of Youth (modified)

PROGRAMMER INSTRUCTIONS

• PRELOAD AND DISPLAY WORK PLACE ADDRESS AS WORK_ADDRESS_1, WORK_ADDRESS_2, WORK_UNIT, WORK_CITY, WORK_STATE, WORK_ZIP, AND WORK_ZIP4 FROM PREGNANCY VISIT 1.

EMP09000. What is the address where you work?

INTERVIEWER INSTRUCTIONS

• PROBE AND ENTER AS MUCH INFORMATION AS PARTICIPANT KNOWS.

SOURCE

Evaluation of the Community Health Marriage Incentive and National Longitudinal Survey of Youth (modified)

(WORK_ADDRESS_1) _________________________________________________

ADDRESS 1 - STREET/PO BOX

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(WORK_ADDRESS_2) ______________________________________________

ADDRESS 2

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(WORK_UNIT) ___________________________________________

UNIT

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(WORK_CITY) ___________________________________________

CITY

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(WORK_STATE) |_____|_____|

STATE

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(WORK_ZIP) |___|___|___|___|___|

ZIP CODE

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(WORK_ZIP4) |___|___|___|___|

ZIP + 4

Label	Code	Go To
REFUSED	-1
DON'T KNOW	-2

(TIME_STAMP_EMP_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

SOCIAL SUPPORT

(TIME_STAMP_SS_ST).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

SS01000. The following questions ask about your feelings and thoughts during the last month. For the following questions, please refer to the card and choose the answer that best describes your life now.

SS02000/(LISTEN). How often is there someone available to you whom you can count on to listen to you when you need to talk? 

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
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	-1
DON'T KNOW	-2

SOURCE

Medical Outcomes Study (modified)

SS03000/(ADVICE). How often is there someone available to give you good advice about a problem?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
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	-1
DON'T KNOW	-2

SOURCE

Medical Outcomes Study (modified)

SS04000/(AFFECTION). How often is there someone available to you who shows you love and affection?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
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	-1
DON'T KNOW	-2

SOURCE

Medical Outcomes Study (modified)

SS05000/(DAILY_HELP). How often is there someone available to help you with daily chores?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
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	1
DON'T KNOW	2

SOURCE

Medical Outcomes Study (modified)

SS06000/(EMOT_SUPPORT). How often can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
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	-1
DON'T KNOW	-2

SOURCE

Medical Outcomes Study (modified)

SS07000/(AMT_SUPPORT). How often do you have as much contact as you would like with someone you feel close to, someone in whom you can trust and confide?

INTERVIEWER INSTRUCTIONS

• IF USING SHOWCARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
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	-1
DON'T KNOW	-2

SOURCE

Medical Outcomes Study (modified)

(TIME_STAMP_SS_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

HEALTH INSURANCE

(TIME_STAMP_HI_ST).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

HI01000. Now I’m going to switch the subject and ask about health insurance.  The next questions are similar to those asked the last time we contacted you, but we are asking them again because sometimes the answers change.

HI02000/(INSURE). Are you currently covered by any kind of health insurance or some other kind of health care plan?

Label	Code	Go To
YES	1
NO	2	TIME_STAMP_HI_ET
REFUSED	-1	TIME_STAMP_HI_ET
DON'T KNOW	-2	TIME_STAMP_HI_ET

SOURCE

American Community Survey 2006 (modified)

HI03000. Now I’ll read a list of different types of insurance. Please tell me which types you currently have.

SOURCE

American Community Survey 2006 (modified)

HI04000/(INS_EMPLOY). Insurance through an employer or union either through yourself or another family member?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (Do you currently have…) AS NEEDED

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey 2006 (modified)

HI05000/(INS_MEDICAID). Medicaid or any government-assistance plan for those with low incomes or a disability?

INTERVIEWER INSTRUCTIONS

• PROVIDE EXAMPLES OF LOCAL MEDICAID PROGRAMS

• RE-READ INTRODUCTORY STATEMENT (Do you currently have…) AS NEEDED

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey 2006 (modified)

HI06000/(INS_TRICARE). TRICARE, VA, or other military health care?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (Do you currently have…) AS NEEDED

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey 2006 (modified)

HI07000/(INS_IHS). Indian Health Service?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (Do you currently have…) AS NEEDED

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey 2006 (modified)

HI08000/(INS_MEDICARE). Medicare, for people with certain disabilities?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (Do you currently have…) AS NEEDED

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey 2006 (modified)

HI09000/(INS_OTH). Any other type of health insurance or health coverage plan?

INTERVIEWER INSTRUCTIONS

• RE-READ INTRODUCTORY STATEMENT (Do you currently have…) AS NEEDED

Label	Code	Go To
YES	1
NO	2
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Community Survey 2006 (modified)

(TIME_STAMP_HI_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

CLOSING SCRIPTS

(TIME_STAMP_CS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• IF PREGNANT = 2, GO TO CS01000.

• OTHERWISE, GO TO CS02000.

CS01000. 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 condolences. Thank you for your time.

INTERVIEWER INSTRUCTIONS

• DO NOT OFFER SAQS.

• END INTERVIEW.

PROGRAMMER INSTRUCTIONS

• IF LOSS_INFO = 1, DISPLAY BRACKETED TEXT:  We’ll send the information packet you requested as soon as possible.

• GO TO TIME_STAMP_CS_ET.

CS02000. Thank you for participating in the National Children’s Study and for taking the time to complete this survey. This concludes the interview.

DATA COLLECTOR INSTRUCTIONS

• EXPLAIN SAQS AND RETURN PROCESS.

• END INTERVIEW.

(TIME_STAMP_CS_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

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.