5.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Pregnancy Visit 2 Questionnaire - Household, Phase 2g

OMB Specification

Pregnancy Visit 2 Questionnaire - Household

Event Category:	Trigger-Based
Event:	PV2
Administration:	N/A
Instrument Target:	Pregnant Woman's Residence
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:	5 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 - Household

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

HOUSING CHARACTERISTICS 3

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Pregnancy Visit 2 Questionnaire - Household

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.

HOUSING CHARACTERISTICS

(TIME_STAMP_HC_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PREGNANT WOMAN'S HOUSEHOLD ID (HH_ID) ​AND RESPONDENT ID (R_P_ID) FOR PREGNANT WOMAN.

HC01000. Now I’d like to find out more about your home and the area in which you live.

HC02000/(RECENT_MOVE). Have you moved or changed your housing situation since we last spoke with you?

Label	Code	Go To
YES	1
NO	2	HC07000
REFUSED	-1	HC07000
DON'T KNOW	-2	HC07000

SOURCE

National Children's Study, Legacy Phase (P1 Mother, T1 Mother)

HC03000/(OWN_HOME). Is your home . . .

Label	Code	Go To
Owned or being bought by you or someone in your household	1	AGE_HOME
Rented by you or someone in your household	2	AGE_HOME
Occupied without payment of rent	3	AGE_HOME
SOME OTHER ARRANGEMENT	-5
REFUSED	-1	AGE_HOME
DON'T KNOW	-2	AGE_HOME

SOURCE

Survey of Income and Program Participation

HC04000/(OWN_HOME_OTH). SPECIFY:  ___________________________________________________

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

SOURCE

Survey of Income and Program Participation

HC05000/(AGE_HOME). Which of these categories best describes when your home or building was built?

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
2001 OR LATER	1
1981 TO 2000	2
1961 TO 1980	3
1941 TO 1960	4
1940 OR BEFORE	5
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Survey of Lead and Allergens in Housing (modified)

HC06000. How long have you lived in this home?

SOURCE

National Survey of Lead and Allergens in Housing

(LENGTH_RESIDE) |_____|_____|

NUMBER

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

(LENGTH_RESIDE_UNIT)

Label	Code	Go To
WEEKS	1
MONTHS	2
YEARS	3

HC07000. Now I’m going to ask about how your home is heated and cooled.

HC08000/(MAIN_HEAT). Which of these types of heat sources best describes the main heating fuel source for your home?

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
ELECTRIC	1	HEAT2
GAS - PROPANE OR LP	2	HEAT2
OIL	3	HEAT2
WOOD	4	HEAT2
KEROSENE OR DIESEL	5	HEAT2
COAL OR COKE	6	HEAT2
SOLAR ENERGY	7	HEAT2
HEAT PUMP	8	HEAT2
NO HEATING SOURCE	9	COOLING
OTHER	-5
REFUSED	-1	COOLING
DON'T KNOW	-2	COOLING

SOURCE

American Healthy Homes Survey

HC09000/(MAIN_HEAT_OTH). SPECIFY:  ____________________________________________________

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

SOURCE

American Healthy Homes Survey

HC10000/(HEAT2). Are there any other types of heat you use regularly during the heating season to heat your home?

INTERVIEWER INSTRUCTIONS

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

• IF NOT USING SHOWCARDS, READ RESPONSE OPTIONS.

• PROBE:  Do you have any space heaters, or any secondary method for heating your home?

• SELECT ALL THAT APPLY.

Label	Code	Go To
ELECTRIC	1
GAS - PROPANE OR LP	2
OIL	3
WOOD	4
KEROSENE OR DIESEL	5
COAL OR COKE	6
SOLAR ENERGY	7
HEAT PUMP	8
NO OTHER HEATING SOURCE	9
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Healthy Homes Survey

PROGRAMMER INSTRUCTIONS

• IF HEAT2 = ANY COMBINATION OF VALUES 1 - 8, GO TO COOLING.

• IF HEAT2 = -5, OR ANY COMBINATION OF VALUES 1 - 8 AND -5, GO TO HEAT2_OTH.

• IF HEAT2 = 9, -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO COOLING.

HC11000/(HEAT2_OTH). SPECIFY:  ____________________________________________________

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

SOURCE

American Healthy Homes Survey

HC12000/(COOLING). Does your home have any type of cooling or air conditioning besides fans?

Label	Code	Go To
YES	1
NO	2	HC15000
REFUSED	-1	HC15000
DON'T KNOW	-2	HC15000

SOURCE

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

HC13000/(COOL). Not including fans, which of the following kinds of cooling systems do you regularly use?

INTERVIEWER INSTRUCTIONS

• SELECT ALL THAT APPLY.

Label	Code	Go To
Window or wall air conditioners	1
Central air conditioning	2
Evaporative cooler, also called swamp cooler	3
NO COOLING OR AIR CONDITIONING REGULARLY USED	4
Some other cooling system	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Survey of Lead and Allergens in Housing and American Healthy Homes Survey

PROGRAMMER INSTRUCTIONS

• IF COOL = ANY COMBINATION OF VALUES 1-3, GO TO HC15000

• IF COOL = -5, OR ANY COMBINATION OF VALUES 1-3 AND -5, GO TO COOL_OTH.

• IF COOL = 4, -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO HC15000.

HC14000/(COOL_OTH). SPECIFY:  ___________________________________________________

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

SOURCE

National Survey of Lead and Allergens in Housing and American Healthy Homes Survey

HC15000. Now I’d like to ask about the water in your home.

HC16000/(WATER_DRINK). What water source in your home do you use most of the time for drinking?

Label	Code	Go To
Tap water	1	WATER_COOK
Filtered tap water	2	WATER_COOK
Bottled water	3	WATER_COOK
Some other source	-5
REFUSED	-1	WATER_COOK
DON'T KNOW	-2	WATER_COOK

SOURCE

National Human Exposure Assessment Survey

HC17000/(WATER_DRINK_OTH). SPECIFY:  ___________________________________________________

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

SOURCE

National Human Exposure Assessment Survey

HC18000/(WATER_COOK). What water source in your home is used most of the time for cooking? 

Label	Code	Go To
Tap water	1	HC20000
Filtered tap water	2	HC20000
Bottled water	3	HC20000
Some other source	-5
REFUSED	-1	HC20000
DON'T KNOW	-2	HC20000

SOURCE

National Human Exposure Assessment Survey

HC19000/(WATER_COOK_OTH). SPECIFY:  ____________________________________________________

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

SOURCE

National Human Exposure Assessment Survey

HC20000. Water damage is a common problem that occurs inside of many homes. Water damage includes water stains on the ceiling or walls, rotting wood, and flaking sheetrock or plaster. This damage may be from broken pipes, a leaky roof, or floods.

HC21000/(WATER). Since we last spoke with you, have you seen any water damage inside your home?

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

SOURCE

American Healthy Homes Survey (modified)

HC22000/(MOLD). Since we last spoke with you, have you seen any mold or mildew on walls or other surfaces other than the shower or bathtub, inside your home?

Label	Code	Go To
YES	1
NO	2	HC25000
REFUSED	-1	HC25000
DON'T KNOW	-2	HC25000

SOURCE

American Healthy Homes Survey (modified)

HC23000/(ROOM_MOLD). In which rooms have you seen the mold or mildew?

INTERVIEWER INSTRUCTIONS

• PROBE:  Any other rooms?

• SELECT ALL THAT APPLY

Label	Code	Go To
KITCHEN	1
LIVING ROOM	2
HALL OR LANDING	3
PARTICIPANT'S BEDROOM	4
OTHER BEDROOM	5
BATHROOM/TOILET	6
BASEMENT	7
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

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

PROGRAMMER INSTRUCTIONS

• IF ROOM_MOLD = ANY COMBINATION OF VALUES 1-7, GO TO HC25000.

• IF ROOM_MOLD = -5, OR ANY COMBINATION OF VALUES 1-7 AND -5, GO TO ROOM_MOLD_OTH.

• IF ROOM_MOLD = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO HC25000.

HC24000/(ROOM_MOLD_OTH). SPECIFY:  ___________________________________________________

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

SOURCE

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

HC25000. The next few questions ask about any recent additions or renovations to your home.  

HC26000/(PRENOVATE2). Since our last contact, have any additions or renovations been done to your home? Include only major projects that made your home larger or involved construction. Do not count smaller projects such as painting or wallpapering, carpeting, or refinishing floors."

Label	Code	Go To
YES	1
NO	2	PDECORATE2
REFUSED	-1	PDECORATE2
DON'T KNOW	-2	PDECORATE2

SOURCE

American Healthy Homes Survey and National Survey of Lead and Allergens in Housing (modified)

HC27000/(PRENOVATE2_ROOM). Which rooms were renovated?

INTERVIEWER INSTRUCTIONS

• PROBE:   Any others?

• SELECT ALL THAT APPLY.

Label	Code	Go To
KITCHEN	1
LIVING ROOM	2
HALL OR LANDING	3
PARTICIPANT'S BEDROOM	4
OTHER BEDROOM	5
BATHROOM/TOILET	6
BASEMENT	7
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

American Healthy Homes Survey and National Survey of Lead and Allergens in Housing (modified)

PROGRAMMER INSTRUCTIONS

• IF PRENOVATE2_ROOM = ANY COMBINATION OF VALUES 1-7, GO TO PDECORATE2.

• IF PRENOVATE2_ROOM = -5, OR ANY COMBINATION OF VALUES 1-7 AND -5,  GO TO PRENOVATE2_ROOM_OTH

• IF PRENOVATE2_ROOM = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO PDECORATE_2.

HC28000/(PRENOVATE2_ROOM_OTH). SPECIFY:  ___________________________________________________

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

SOURCE

American Healthy Homes Survey and National Survey of Lead and Allergens in Housing (modified)

HC29000/(PDECORATE2). Since we last spoke with you, were any smaller projects done in your home, such as painting, wallpapering, refinishing floors, or installing new carpet?

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

SOURCE

Avon Longitudinal Study of Parents and Children

HC30000/(PDECORATE2_ROOM). In which rooms were these smaller projects done?

INTERVIEWER INSTRUCTIONS

• PROBE:  Any others?

• SELECT ALL THAT APPLY

Label	Code	Go To
KITCHEN	1
LIVING ROOM	2
HALL OR LANDING	3
PARTICIPANT'S BEDROOM	4
OTHER BEDROOM	5
BATHROOM/TOILET	6
BASEMENT	7
OTHER	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

Avon Longitudinal Study of Parents and Children (modified)

PROGRAMMER INSTRUCTIONS

• IF PDECORATE2_ROOM = ANY COMBINATION OF VALUES 1 - 7, GO TO TIME_STAMP_HC_ET.

• IF PDECORATE2_ROOM = -5, OR ANY COMBINATION OF VALUES 1 - 7 AND -5, GO TO PDECORATE2_ROOM_OTH.

• IF PDECORATE2_ROOM = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_HC_ET.

HC31000/(PDECORATE2_ROOM_OTH). SPECIFY:  ____________________________________________________

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

SOURCE

Avon Longitudinal Study of Parents and Children

(TIME_STAMP_HC_ET).

PROGRAMMER INSTRUCTIONS

INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 5 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.