16.6 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

24M Questionnaire – Adult, Phase 2g

OMB Specification

24M Questionnaire – Adult

Event Category:	Time-Based
Event:	24M
Administration:	N/A
Instrument Target:	Primary Caregiver
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:	4 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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24M Questionnaire – Adult

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

ADULT CAREGIVER BEHAVIORS 3

REACTIONS TO RACE 5

IMMIGRATION STATUS 8

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24M 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.

ADULT CAREGIVER BEHAVIORS

(TIME_STAMP_PB_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

• PRELOAD PARTICIPANT ID (P_ID) AND RESPONDENT ID (R_P_ID) FOR ADULT CAREGIVER.

PB01000/(DRINK). Do you drink any type of alcoholic beverage?

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

SOURCE

Early Childhood Longitudinal Program, Birth Cohort Pre-School Parent Interview (modified)

PB02000/(DRINK_NOW). How often do you currently drink alcoholic beverages?

Label	Code	Go To
5 or more times a week	1
2-4 times a week	2
Once a week	3
1-3 times a month	4
Less than once a month	5
Never	6	TIME_STAMP_PB_ET
REFUSED	-1	TIME_STAMP_PB_ET
DON'T KNOW	-2	TIME_STAMP_PB_ET

SOURCE

National Health Interview Survey 2003 Adult Section (modified)

PB03000/(DRINK_NOW_NUM). Currently, on days that you drink alcoholic beverages, how many drinks do you have per day?  If you drink 1 or less, please report 1.

 

|___|___|___|

NUMBER OF DRINKS

INTERVIEWER INSTRUCTIONS

• IF RESPONDENT DRINKS LESS THAN 1 DRINK, ENTER "001".

• IF NEEDED SAY, "By a drink, we mean a can or bottle of beer, a glass of wine or wine cooler, a shot of liquor, or a mixed drink with liquor in it.  We are not asking about times when you only had a sip or two from a drink."

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

SOURCE

Pregnancy Risk Assessment Monitoring System (modified)

PB04000/(DRINK_NOW_5). How often do you have 5 or more drinks within a couple of hours:

Label	Code	Go To
Never	1
About once a month	2
About once a week	3
About once a day	4
REFUSED	-1
DON'T KNOW	-2

SOURCE

National Health Interview Survey 2003 Adult Section (modified)

(TIME_STAMP_PB_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

REACTIONS TO RACE

(TIME_STAMP_RTR_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

RTR01000. The next questions are about how other people identify your race and treat you. 

RTR02000/(OTHERS_CLASSIFY). How do other people usually classify you in this country? 

Label	Code	Go To
White	1	THINK_RACE
Black or African American	2	THINK_RACE
Hispanic or Latino	3	THINK_RACE
Asian	4	THINK_RACE
Native Hawaiian or Other Pacific Islander	5	THINK_RACE
American Indian or Alaska Native	6	THINK_RACE
SOME OTHER GROUP	-5
REFUSED	-1	THINK_RACE
DON'T KNOW	-2	THINK_RACE

SOURCE

Behavioral Risk Factor Surveillance System 2011 

RTR03000/(OTHERS_CLASSIFY_OTH). SPECIFY: _____________________________

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

SOURCE

Behavioral Risk Factor Surveillance System 2011 

RTR04000/(THINK_RACE). How often do you think about your race? 

Label	Code	Go To
Never	1
Once a year	2
Once a month	3
Once a week	4
Once a day	5
Once an hour	6
Constantly	7
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System 2011 (modified)

RTR05000/(TREATED_RACE). Within the past 12 months, do you feel you were treated worse than, the same as, or better than people of other races? 

Label	Code	Go To
WORSE THAN OTHER RACES	1
THE SAME AS OTHER RACES	2
BETTER THAN OTHER RACES	3
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System 2011 (modified)

RTR06000/(HEALTH_RACE). Within the past 12 months, when seeking health care, do you feel your experiences were worse than, the same as, or better than for people of other races?

Label	Code	Go To
WORSE THAN OTHER RACES	1
THE SAME AS OTHER RACES	2
BETTER THAN OTHER RACES	3
DID NOT SEEK HEALTH CARE IN THE PAST 12 MONTHS	-7
REFUSED	-1
DON'T KNOW	-2

SOURCE

Behavioral Risk Factor Surveillance System 2011 (modified)

RTR07000/(PHYSICAL_RACE). Within the past 30 days, have you experienced any physical symptoms, for example, a headache, an upset stomach, tensing of your muscles, or a pounding heart, as a result of how you were treated based on your race?

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

SOURCE

Behavioral Risk Factor Surveillance System 2011 (modified)

RTR08000/(EMOTIONAL_RACE). Within the past 30 days, have you felt emotionally upset, for example angry, sad, or frustrated, as a result of how you were treated based on your race?

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

SOURCE

Behavioral Risk Factor Surveillance System 2011 (modified)

(TIME_STAMP_RTR_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

IMMIGRATION STATUS

(TIME_STAMP_IS_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

IS01000. Next, we would like to ask you some questions about your country of birth and time in the U.S.

           

Please remember that all information you provide remains confidential. This information is important to collect since child health outcomes may be influenced by the birthplace of the child, the parents, or other family members. We are interested in learning what factors influence health among children of immigrants and children of parents born in the U.S. You do not need to answer any question that makes you uncomfortable.

IS02000. Where were you born?  What city and state?

INTERVIEWER INSTRUCTIONS

• PROBE, “Was this in the United States?”

• ASK RESPONDENT WHAT COUNTRY IF YOU CANNOT CONFIRM THE COUNTRY AS THE UNITED STATES.

• VERIFY THE SPELLING OF THE CITY, STATE, AND COUNTRY.

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006. “The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

(BORN_CITY)  

___________________________________

CITY

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

(BORN_STATE)  

______________________________________________

STATE/PROVINCE/TERRITORY

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

(BORN_COUNTRY)
_____________________________________

COUNTRY

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

IS03000/(BORN_US). WHERE WAS PARTICIPANT BORN?

INTERVIEWER INSTRUCTIONS

• THIS IS AN INTERVIEWER-COMPLETED QUESTION.

• US TERRITORIES INCLUDE PUERTO RICO, GUAM, AND AMERICAN SAMOA.

Label	Code	Go To
BORN IN USA	1	TIME_STAMP_IS_ET
BORN IN PUERTO RICO OR OTHER US TERRITORY	2	TIME_STAMP_IS_ET
NOT BORN IN USA OR US TERRITORY	3
REFUSED	-1	TIME_STAMP_IS_ET
DON'T KNOW	-2	TIME_STAMP_IS_ET

IS04000/(US_YEAR). In what year did you first come to the United States to live or work?  Please do not include short trips for shopping, vacation or family visits.

 

|___|___|___|___|

YEAR

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

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006. “The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

IS05000/(US_CITIZEN). Are you a citizen of the United States?

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

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006. “The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

IS06000/(CITIZEN_HOW). How did you become a citizen of the United States?

Label	Code	Go To
Born abroad to American citizen parents	1	TIME_STAMP_IS_ET
Naturalization	2	TIME_STAMP_IS_ET
Through naturalization of one or both parents	3	TIME_STAMP_IS_ET
Through own or spouse’s military service	4	TIME_STAMP_IS_ET
Adopted by U.S. citizen parents	5	TIME_STAMP_IS_ET
REFUSED	-1	TIME_STAMP_IS_ET
DON'T KNOW	-2	TIME_STAMP_IS_ET

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006. “The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

IS07000/(GREEN_CARD). Do you currently have a permanent residence card or a green card?

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

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006. “The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

IS08000/(IMMIGRANT_STATUS). Have you been granted asylum, refugee status, or temporary protected immigrant status (TPS)?

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

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006. “The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

IS09000/(HAVE_VISA). Do you have a tourist visa, a student visa, a work visa or permit, or another document which permits you to stay in the U.S. for a limited time?

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

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006. “The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

IS10000/(VISA_VALID). Is the visa or document still valid or has it expired?

Label	Code	Go To
STILL VALID	1
HAS EXPIRED	2
REFUSED	-1
DON’T KNOW	-2

SOURCE

Sastry, Narayan, Bonnie Ghosh-Dastidar, John Adams, and Anne R. Pebley.  2006. “The Design of a Multilevel Survey of Children, Families, and Communities:  The Los Angeles Family and Neighborhood Survey.”  Social Science Research 35(4): 1000-1024

(TIME_STAMP_IS_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 4 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.