Form 13.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

9M Questionnaire - Child, Phase 2g

OMB Specification

9M Questionnaire - Child

Event Category:	Time-Based
Event:	9M
Administration:	N/A
Instrument Target:	Child
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:	3 minutes
Multiple Child/Sibling Consideration:	Per Child
Special Considerations:	N/A
Version:	3.0
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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9M Questionnaire - Child

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

CHILD DEVELOPMENT 3

HEALTH CARE 9

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9M Questionnaire - Child

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	CHARACTER
ZIP CODE LAST FOUR	4	CHARACTER
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
NUMBER OF HOURS PER DAY	TWO-DIGIT HOUR	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 1 AND 24
NUMBER OF DAYS PER WEEK	ONE-DIGIT	NUMERIC	HARD EDITS: DAYS PER WEEK MUST BE BETWEEN 1 AND 7

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.

CHILD DEVELOPMENT

(TIME_STAMP_CD_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

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

• PRELOAD FIRST NAME OF CHILD (C_FNAME) FROM  PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE AND DISPLAY APPROPRIATE NAME IN “C_FNAME” THROUGHOUT THE INSTRUMENT.

• OTHERWISE, IF C_FNAME IN PARTICIPANT VERIFICATION, SCHEDULING, & TRACING = -1 OR -2, DISPLAY “the child” IN APPROPRIATE FIELDS THROUGHOUT THE INSTRUMENT.

• IF CHILD_SEX IN PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE = 1, DISPLAY “his”, “he”, OR “himself” IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

• IF CHILD_SEX IN PARTICIPANT VERIFICATION, SCHEDULING, & TRACING QUESTIONNAIRE = 2, DISPLAY “her”, “she”, OR “herself” IN APPROPRIATE FIELDS THROUGHOUT INSTRUMENT.

CD01000. First, I will read you a list of things {C_FNAME/the child} may already do or may start doing when {he/she} gets older.  Does {C_FNAME/the child}:

CD02000/(EYES_FOLLOW). Follow you with {his/her} eyes?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Young Baby Girl Questionnaire (modified) 

CD03000/(SMILE). Smile when you smile at {him/her}?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified) 

CD04000/(REACH_1). Try to get a toy that is out of reach?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified) 

CD05000/(FEED). Feed {himself/herself} a cracker or cereal?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified) 

CD06000/(WAVE). Wave goodbye?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Infant Son Questionnaire (modified) 

CD07000/(GRAB). Grab an object like a block or rattle from you?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified) 

CD08000/(SWITCH_HANDS). Move a toy or block from one hand to the other?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified) 

CD09000/(PICKUP). Pick up a small object like a Cheerio or raisin?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified )

CD10000/(HOLD). Hold two toys or blocks at a time, one in each hand?

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

SOURCE

Herald Study Instrument #23 Six-Month Home Interview (modified) 

CD11000/(SOUND_3). Turn toward someone when they’re speaking?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified)

CD12000/(SPEAK_1). Make sounds as though {he/she} is trying to speak?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified) 

CD13000/(SPEAK_2). Say mama or dada?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified) 

CD14000/(HEADUP). Keep {his/her} head steady when sitting or held up?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified) 

CD15000/(ROLL_2). Roll from back to stomach?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified) 

CD16000/(SITUP). Sit up by {himself/herself}?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified) 

CD17000/(STAND). Stand while holding onto something?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Daughter Questionnaire (modified) 

CD18000/(STAND_ALONE). Stand alone, without holding onto something?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Girl Toddler Questionnaire (modified) 

CD19000/(WALK). Walk by {himself/herself}, without holding onto something?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Girl Toddler Questionnaire (modified) 

CD20000/(SCRIBBLE). Scribble or draw with a pencil, crayon, or marker?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Girl Toddler Questionnaire (modified)

CD21000/(FORK_SPOON). Try to use a fork or spoon when eating?

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

SOURCE

Avon Longitudinal Study of Parents and Children My Girl Toddler Questionnaire (modified)

(TIME_STAMP_CD_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

HEALTH CARE

(TIME_STAMP_HC_ST).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

HC01000. The next questions are about {C_FNAME/the child}’s health care.

HC02000/(R_HCARE). First, what kind of place does {C_FNAME/the child} usually go to when {he/she} needs routine or well-child care, such as a check-up or well-baby shots (immunizations)?

Label	Code	Go To
Clinic or health center	1	C_HEALTH
Doctor's office or Health Maintenance Organization (HMO)	2	C_HEALTH
Hospital emergency room	3	C_HEALTH
Hospital outpatient department	4	C_HEALTH
Some other place	-5
DOESN'T GO TO ONE PLACE MOST OFTEN	5	C_HEALTH
DOESN'T GET WELL-CHILD CARE ANYWHERE	-7	C_HEALTH
REFUSED	-1	C_HEALTH
DON’T KNOW	-2	C_HEALTH

SOURCE

National health Interview Survey (NHIS) 2007 Child Access to Health Care & Utilization (modified) 

HC03000/(R_HCARE_OTH). SPECIFY: ________________________

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

SOURCE

National health Interview Survey (NHIS) 2007 Child Access to Health Care & Utilization (modified) 

HC04000/(C_HEALTH). Would you say {C_FNAME/the child}’s health in general is poor, fair, good, or excellent?

Label	Code	Go To
POOR	1
FAIR	2
GOOD	3
EXCELLENT	4
REFUSED	-1
DON’T KNOW	-2

SOURCE

National Health Interview Survey 2010 Family Health Status & Limitations (modified)

HC05000/(USE_IC_LOG). Are you using the Infant and Child Health Care Log? This is the booklet that you or your health care provider (pediatrician or family medicine doctor, specialist (like a surgeon, heart, allergy, or skin doctor), nurse practitioner, physician assistant, nurse, social worker/counselor, etc.) uses to record information about the child’s medical visits.

INTERVIEWER INSTRUCTIONS

• READ TEXT IN PARENTHESES IF NEEDED.

Label	Code	Go To
YES	1	NUM_PROV_IC_LOG
NO	2
REFUSED	-1	HC12000
DON'T KNOW	-2	HC12000

SOURCE

National Children’s Study, Vanguard Phase (3M)

HC06000/(REASON_NO_IC_LOG). Is that because

INTERVIEWER INSTRUCTIONS

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

Label	Code	Go To
The child hasn’t had a medical visit since our last interview	1	HC14000
You’ve misplaced the log	2	HC12000
You’ve forgotten to bring it to the child’s medical visits	3	HC09000
The log was too much trouble to complete	4	HC09000
The log was too difficult to understand	5	HC12000
OTHER	-5
REFUSED	-1	HC09000
DON’T KNOW	-2	HC09000

SOURCE

National Children’s Study, Vanguard Phase (3M)

HC07000/(REASON_NO_IC_LOG_OTH). SPECIFY: _______________________________

Label	Code	Go To
REFUSED	-1	HC12000
DON"T KNOW	-2	HC12000

SOURCE

National Children’s Study, Vanguard Phase (3M)

PROGRAMMER INSTRUCTIONS

• GO TO HC12000.

HC09000. 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 the child’s medical visits.

PROGRAMMER INSTRUCTIONS

• GO TO HC12000.

HC10000/(NUM_PROV_IC_LOG). How many health care providers has the child seen since you first started using this Infant and Child Health Care Log?

 

|___|___|

NUMBER OF PROVIDERS

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

SOURCE

National Children’s Study, Vanguard Phase (3M) (modified)

PROGRAMMER INSTRUCTIONS

• IF NUM_PROV_IC_LOG = 0, -1, OR -2, GO TO HC12000.

• OTHERWISE, GO TO NUM_PROV_REC.

HC11000/(NUM_PROV_REC). Of those providers that {C_FNAME/the child} has 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 (3M) (modified)

HC12000. I am now going to ask some questions about the child’s visits to a doctor or other health care provider. It would be helpful if you referred to {the Infant and Child Health Care Log that you received as part of this study or to} personal records or a 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.

INTERVIEWER INSTRUCTIONS

• READ TEXT IN PARENTHESES IF NEEDED.

PROGRAMMER INSTRUCTIONS

• IF USE_IC_LOG = 1, DISPLAY "the Infant and Child Health Care Log that you received as part of this study or to". 

HC13000. What was the date of {C_FNAME/the child}’s most recent well-child visit or checkup?

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 (3M Phone, 6M Mother, 9M Phone)

(LAST_VISIT_MM) MONTH:

 

|___|___|

  M   M

Label	Code	Go To
HAS NOT HAD A VISIT	-7	SAME_CARE
REFUSED	-1	SAME_CARE
DON’T KNOW	-2	SAME_CARE

(LAST_VISIT_DD) DAY:

 

|___|___|

   D    D

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

(LAST_VISIT_YYYY) YEAR:

 

|___|___|___|___|

  Y     Y     Y    Y

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

PROGRAMMER INSTRUCTIONS

• IF LAST_VISIT_YYYY <> -1 OR -2, AND

• IF USE_IC_LOG = 1, GO TO HC14000.

• IF USE_IC_LOG = 2, -1 OR -2, GO TO SAME_CARE.?

• IF LAST_VISIT_YYYY = -1 OR -2, GO TO SAME_CARE.

HC14000. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Infant and Child Health Care Log.

HC14100/(VISIT_WT). What was {C_FNAME/the child}'s weight at that visit?

 

|___|___|

POUNDS

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

SOURCE

​National Children’s Study, Legacy Phase (3M Phone, 6M Mother, 9M Phone, 12M Mother)

HC15000/(SAME_CARE). If {C_FNAME/the child} is sick or if you have concerns about {his/her} health, does {he/she} go to the same place as for well-child visits?

Label	Code	Go To
YES	1	HOSPITAL
NO	2
NOT APPLICABLE/HAS NOT BEEN SICK	-7	TIME_STAMP_HC_ET
REFUSED	-1
DON’T KNOW	-2

SOURCE

National Children’s Study, Vanguard Phase (9M)

HC16000/(HCARE_SICK). What kind of place does {C_FNAME/the child} usually go to when {he/she} is sick, doesn’t feel well, or if you have concerns about {his/her} health?

Label	Code	Go To
Clinic or health center	1	HOSPITAL
Doctor's office or Health Maintenance Organization (HMO)	2	HOSPITAL
Hospital emergency room	3	HOSPITAL
Hospital outpatient department	4	HOSPITAL
Some other place	-5
DOESN'T GO TO ONE PLACE MOST OFTEN	5	HOSPITAL
NOT APPLICABLE/HAS NOT BEEN SICK	-7	TIME_STAMP_HC_ET
REFUSED	-1	HOSPITAL
DON’T KNOW	-2	HOSPITAL

SOURCE

National Health Interview Survey (NHIS)

HC17000/(HCARE_SICK_OTH). SPECIFY: ________________________

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

SOURCE

National Health Interview Survey (NHIS)

HC18000/(HOSPITAL). Since {DATE OF LAST INTERVIEW}, has {C_FNAME/the child} spent at least one night in the hospital?

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

National Health Interview Survey 2007 Family Interview (modified) 

PROGRAMMER INSTRUCTIONS

• PRELOAD AND DISPLAY THE DATE OF THE LAST INTERVIEW IN "{DATE OF LAST INTERVIEW}".

HC19000/(HOSPITAL_TIMES). How many times since {DATE OF LAST INTERVIEW} has {C_FNAME/the child} spent at least one night in the hospital?

 

 

|___|___|

TIMES

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

SOURCE

National Health Interview Survey 2007 Family Interview (modified) 

DATA COLLECTOR INSTRUCTIONS

• LOOP THROUGH ADMIN_DATE_MM, ADMIN_DATE_DD, ADMIN_DATE_YYYY, HOSP_NIGHTS, DIAGNOSE, DIAGNOSES (IF DIAGNOSE = 1), AND HC24000 (IF USE_IC_LOG = 1) FOR EACH HOSPITAL ADMISSION UNTIL TOTAL NUMBER OF LOOPS = HOSPITAL_TIMES .

HC20000. What was the admission date of {C_FNAME/the child}’s {most recent/next most recent} hospital stay?

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 Mom, T3 Prior)

(ADMIN_DATE_MM) MONTH:

|___|___|

   M    M

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

(ADMIN_DATE_DD) DAY:

 

|___|___|

   D    D

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

(ADMIN_DATE_YY) YEAR:

 

|___|___|___|___|

  Y     Y     Y    Y

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

PROGRAMMER INSTRUCTIONS

• IF FIRST LOOP, DISPLAY “most recent”.

• OTHERWISE, DISPLAY “next most recent”.

HC21000/(HOSP_NIGHTS). How many nights did {C_FNAME/the child} 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

National Health Interview Survey 2007 Family Interview (modified) 

HC22000/(DIAGNOSE). Did a doctor or other health care provider give you a diagnosis for {C_FNAME/the child} during this hospital stay?

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

SOURCE

National Children’s Study, Legacy Phase (3M Phone, 6M Mother, 12M Mother)

PROGRAMMER INSTRUCTIONS

• IF DIAGNOSE = 1, GO TO DIAGNOSES.

• IF DIAGNOSE = 2, -1, OR -2 AND USE_IC_LOG =1, GO TO HC24000.

• IF DIAGNOSE = 2, -1, OR -2, AND USE_IC_LOG = 2, -1, OR -2, AND

• IF NUMBER OF LOOPS = HOSPITAL_TIMES, GO TO TIME_STAMP_HC_ET.

• IF NUMBER OF LOOPS < HOSPITAL_TIMES, GO TO HC20000.

HC23000/(DIAGNOSES). What was the diagnosis?

________________________________

DIAGNOSES

INTERVIEWER INSTRUCTIONS

• ENTER ALL DIAGNOSES IN FIELD SEPARATED BY COMMAS OR AN “AND”.

• PROBE: “Anything else?”

SOURCE

National Children’s Study, Legacy Phase (3M Phone, 6M Mother, 12M Mother)

PROGRAMMER INSTRUCTIONS

• IF USE_IC_LOG = 1, GO TO HC24000.

• IF USE_IC_LOG = 2, -1 OR -2, AND

• IF NUMBER OF LOOPS = HOSPITAL_TIMES, GO TO TIME_STAMP_HC_ET.

• IF NUMBER OF LOOPS < HOSPITAL_TIMES, GO TO HC20000.

HC24000. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Infant and Child Health Care Log.

PROGRAMMER INSTRUCTIONS

• IF NUMBER OF LOOPS = HOSPITAL_TIMES, GO TO TIME_STAMP_HC_ET.

• IF NUMBER OF LOOPS < HOSPITAL_TIMES, GO TO HC20000.

(TIME_STAMP_HC_ET).

PROGRAMMER INSTRUCTIONS

• INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 3 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.