Form 2.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Pre-Pregnancy Questionnaire - Household, Phase 2g

OMB Specification

Pre-Pregnancy Questionnaire - Household

Event Category:	Trigger-Based
Event:	Pre-Pregnancy
Administration:	N/A
Instrument Target:	Pre-Pregnant Woman's Residence
Instrument Respondent:	Pre-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:	6 minutes
Multiple Child/Sibling Consideration:	Per Event
Special Considerations:	N/A
Version:	1.0
MDES Release:	MDES 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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Pre-Pregnancy Questionnaire - Household

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

HOUSING CHARACTERISTICS 3

FAMILY INCOME 13

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Pre-Pregnancy 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 PRE-PREGNANT WOMAN'S HOUSEHOLD ID (HH_ID) AND RESPONDENT ID (R_P_ID) FOR ADULT.

• PRELOAD OWN_HOME FROM PREGNANCY SCREENER (INSTRUMENT_ID = XX) IF AVAILABLE.

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

PROGRAMMER INSTRUCTIONS

• IF OWN_HOME COLLECTED IN PREGNANCY SCREENER (INSTRUMENT_ID = XX), GO TO RECENT_MOVE

• OTHERWISE, GO TO OWN_HOME

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

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

SOURCE

National Children’s Study, Vanguard Phase

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

National Children’s Study, Vanguard Phase

HC04000/(OWN_HOME_OTH). SPECIFY: _____________________________

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

SOURCE

National Children’s Study, Vanguard Phase

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

INTERVIEWER INSTRUCTIONS

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

• IF NOT USING SHOW CARDS, 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	HC07000
DON'T KNOW	-2	HC07000

(LENGTH_RESIDE_UNIT)

Label	Code	Go To
WEEKS	1
MONTHS	2
YEARS	3
REFUSED	-1
DON'T KNOW	-2

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 SHOW CARDS, DO NOT READ RESPONSE OPTIONS AND REFER TO APPROPRIATE SHOWCARD.

• IF NOT USING SHOW CARDS, READ RESPONSE OPTIONS.

• PROBE FOR ANY OTHER RESPONSES: 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, THEN 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, Vanguard Phase

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

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES

• 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	-7
Some other cooling system	-5
REFUSED	-1
DON'T KNOW	-2

SOURCE

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, -7, -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

American Healthy Homes Survey

HC15000. 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.

HC16000/(WATER). In the past 12 months, 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)

HC17000/(MOLD). In the past 12 months, 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	HC20000
REFUSED	-1	HC20000
DON'T KNOW	-2	HC20000

SOURCE

American Healthy Homes Survey (modified)

HC18000/(ROOM_MOLD). In which rooms have you seen the mold or mildew?

INTERVIEWER INSTRUCTIONS

• PROBE FOR ANY OTHER RESPONSES: 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, Vanguard Phase

PROGRAMMER INSTRUCTIONS

• IF ROOM_MOLD = ANY COMBINATION OF VALUES 1 – 7, GO TO HC20000.

• 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 HC20000.

HC19000/(ROOM_MOLD_OTH). SPECIFY: _____________________________

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

SOURCE

National Children’s Study, Vanguard Phase

HC20000. The next few questions ask about any recent additions or renovations to your home. 

HC21000/(RENOVATE). In the past 12 months, 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	DECORATE
REFUSED	-1	DECORATE
DON'T KNOW	-2	DECORATE

SOURCE

American Housing Survey

HC22000/(RENOVATE_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 Housing Survey

PROGRAMMER INSTRUCTIONS

• IF RENOVATE_ROOM = ANY COMBINATION OF VALUES 1 – 7, THEN GO TO DECORATE.

• IF RENOVATE_ROOM = -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO RENOVATE_ROOM_OTH. 

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

HC23000/(RENOVATE_ROOM_OTH). SPECIFY: _____________________________

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

SOURCE

American Housing Survey

HC24000/(DECORATE). In the past 12 months, 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	HC27000
REFUSED	-1	HC27000
DON'T KNOW	-2	HC27000

SOURCE

Avon Longitudinal Study of Parents and Children

HC25000/(DECORATE_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

PROGRAMMER INSTRUCTIONS

• IF DECORATE_ROOM = ANY COMBINATION OF VALUES 1 – 7, THEN GO TO HC27000.

• IF DECORATE_ROOM = -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO DECORATE_ROOM_OTH. 

• IF DECORATE_ROOM = -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO HC27000.

HC26000/(DECORATE_ROOM_OTH). SPECIFY: _____________________________

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

SOURCE

Avon Longitudinal Study of Parents and Children

HC27000. Now I’d like to ask about the water in your home.

HC28000/(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

HC29000/(WATER_DRINK_OTH). SPECIFY: _____________________________

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

SOURCE

National Human Exposure Assessment Survey

HC30000/(WATER_COOK). What water source in your home is used most of the time for cooking?

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

SOURCE

National Human Exposure Assessment Survey

HC31000/(WATER_COOK_OTH). SPECIFY: _____________________________

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

SOURCE

National Human Exposure Assessment Survey

(TIME_STAMP_HC_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

FAMILY INCOME

(TIME_STAMP_FI_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

FI01000. Now I’m going to ask a few questions about your income.   Family income is important in analyzing the data we collect and is often used in scientific studies to compare groups of people who are similar.  Please remember that all the information you provide is confidential.

 

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

PROGRAMMER INSTRUCTIONS

• CALCULATE AND DISPLAY CURRENT YEAR MINUS 1.

FI02000/(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

National Children’s Study, Vanguard Phase

PROGRAMMER INSTRUCTIONS

• RESPONSE MUST BE > 0; INCLUDE A SOFT EDIT IF RESPONSE IS > 15

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

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

FI03000 /(NUM_CHILD). 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

Survey of Income and Program Participation

PROGRAMMER INSTRUCTIONS

• INCLUDE HARD EDIT IF RESPONSE > HH_MEMBERS

• INCLUDE SOFT EDIT IF RESPONSE > 10

FI01000/(INCOME). Of these income groups, which category best represents your total combined family income during the last calendar year?

INTERVIEWER INSTRUCTIONS

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

• IF NOT USING SHOW CARDS, READ RESPONSE OPTIONS.

Label	Code	Go To
LESS THAN $4,999	1
$5,000-$9,999	2
$10,000-$19,999	3
$20,000-$29,999	4
$30,000-$39,999	5
$40,000-$49,999	6
$50,000-$74,999	7
$75,000-$99,999	8
$100,000-$199,999	9
$200,000 OR MORE	10
REFUSED	-1
DON'T KNOW	-2

SOURCE

Survey of Income and Program Participation (modified)

(TIME_STAMP_FI_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 6 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.