11.8 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

3M Questionnaire - Household, Phase 2g

OMB Specification

3M Questionnaire - Household

Event Category:	Time-Based
Event:	3M
Administration:	N/A
Instrument Target:	Child's Primary Residence
Instrument Respondent:	Primary Caregiver
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:	1 minute
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.

This page intentionally left blank.

3M Questionnaire - Household

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

INCOME 3

This page intentionally left blank.

3M 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.

INCOME

(TIME_STAMP_INC_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PRIMARY RESIDENCE ID (VARIABLE NAME) AND RESPONDENT ID (R_P_ID) FOR ADULT CAREGIVER.

INC01000. Now I’m going to ask a few questions about your income. Family income is important in understanding the information we collect and is often used in scientific studies to compare groups of people who are similar. Please remember that all the information you share with us is confidential.

 

Please think about your total combined family income during {CURRENT YEAR – 1} for all members of the family. 

PROGRAMMER INSTRUCTIONS

• PRELOAD CURRENT YEAR.

• DISPLAY CURRENT YEAR MINUS 1.

INC02000/(HH_MEMBERS). How many household members are supported by your total combined family income?

 

|___|___|

NUMBER

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

SOURCE

NCS Herald Cohort Study Instrument #20 (modified)

PROGRAMMER INSTRUCTIONS

• DISPLAY HARD EDIT IF RESPONSE < 0.

• DISPLAY SOFT EDIT IF RESPONSE IS > 15.

• IF HH_MEMBERS = 1, -1, OR -2, GO TO INCOME_4CAT. 

• OTHERWISE, IF HH_MEMBERS > 1, GO TO NUM_CHILD.

INC03000/(NUM_CHILD). How many of the people supported by your income are children? How many of those people are children? Please include anyone under 18 years or anyone older than 18 years and in high school.

 

|___|___|

NUMBER

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

SOURCE

NCS Herald Cohort Study Instrument #20 (modified)

PROGRAMMER INSTRUCTIONS

• DISPLAY HARD EDIT IF RESPONSE > HH_MEMBERS.

• DISPLAY SOFT EDIT IF RESPONSE > 10.

INC04000/(INCOME_4CAT). Of these income groups, which category best represents your total combined family income during the last calendar year?

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
LESS THAN $30,000	1
$30,000 - $49,999	2
$50,000 - $99,999	3
$100,000 OR MORE	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Children’s Study Vanguard Phase  

(TIME_STAMP_INC_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 1 minute 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.