Form 39.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Participant Information Update (SAQ), Phase 2g

OMB Specification

Participant Information Update Gift Incentive Later SAQ

Event Category:	Time-Based
Event:	24M, 30M, 36M, 42M, 48M, 54M, 60M
Administration:	N/A
Instrument Target:	Primary Caregiver
Instrument Respondent:	Primary Caregiver
Domain:	Questionnaire
Document Category:	Questionnaire
Method:	Self-Administered
Mode (for this instrument*):	In-Person, PAPI
OMB Approved Modes:	In-Person, PAPI; Phone, PAPI; 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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Participant Information Update Gift Incentive Later SAQ

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

PARTICIPANT INFORMATION UPDATE 3

FOR OFFICE USE ONLY 11

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Participant Information Update Gift Incentive Later SAQ

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.

PARTICIPANT INFORMATION UPDATE

PIU01000. Thank you for participating in the National Children’s Study.  To make sure we can reach you for your next Study visit please answer a few questions about how to best find you.  The survey should only take about 5 minutes to complete.  We have included a postage-paid envelope for you to mail it back to us. 

 

Your participation in the Study is very important to us. As a token of our appreciation for your involvement, we will send a small gift for your child when we receive your completed survey.

 

There are no right or wrong answers. You can skip over any question. We will keep everything that you tell us confidential.

PIU02000. What is your first and last name?

SOURCE

National Children's Study, Legacy Phase (Modified)

(R_FNAME) First Name: ____________________________________________

(CHILD2_AGE) Child's Age: l___l___l months

(R_LNAME) Last Name: ____________________________________________

PIU03000. What is the first name and age of the child enrolled in the National Children’s Study?

SOURCE

New

(CHILD1_FNAME) Child's First Name: ____________________________________________

(CHILD1_AGE) Child's Age: l___l___l months

PIU03100. If you have more than one child enrolled in the Study, please provide their names and ages below.

SOURCE

New

(CHILD2_FNAME) Child's First Name: ____________________________________________

(CHILD3_FNAME) Child's First Name: ____________________________________________

(CHILD3_AGE) Child's Age: l___l___l months

(CHILD4_FNAME) Child's First Name: ____________________________________________

(CHILD4_AGE) Child's Age:  l___l___l months

PIU04000/(R_REL_CHILD). What is your relationship to the child?  Are you his/her…

Label	Code	Go To
Mother/Father	1
Aunt/Uncle	2
Grandmother/Grandfather	3
Other Relative	4
Other Primary Caregiver	5
Other	-5

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

PIU04100/(R_REL_CHILD_OTH). Please specify: ________________________________________

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

PIU05000/(CELL_NUM). What is your cell phone number?

 

_____________________________________________

Label	Code	Go To
Do not have a cell phone	-1

SOURCE

National Children's Study, Legacy Phase (6M Mother)

PIU06000/(HOME_NUM). What is your home phone number?

 

__________________________________________

Label	Code	Go To
Do not have a home phone/land line	-1

SOURCE

National Children's Study, Legacy Phase (Pregnancy Screener)

PIU07000/(WORK_NUM). What is your office phone number?

 

____________________________________________

Label	Code	Go To
Do not have an office/work phone	-1

SOURCE

New

PIU08000/(EMAIL_ADD). What is your email address?

 

______________________________________

Label	Code	Go To
Do not have an email address	-1

SOURCE

National Children's Study, Legacy Phase (Pregnancy Screener)

PIU09000/(BEST_CONTACT). What is the best way to get in touch with you?

Label	Code	Go To
Cell phone	1
Home phone	2
Office phone	3
Email	4
Text Message	5
Social Media (such as Facebook)	6
Other	-5

SOURCE

New

PIU09100/(BEST_CONTACT_FB_OTH). Please specify: ________________________________________

SOURCE

New

PIU09200/(BEST_CONTACT_OTH). Please specify: ___________________________________________

SOURCE

New

PIU10000/(PLAN_MOVE). Do you plan on moving from your current address in the next few months?

Label	Code	Go To
Yes	1
No	2	ADULT_HH

SOURCE

National Children's Study, Legacy Phase (Pregnancy Screener)

PIU11000. What is the address of your new home?        

Label	Code	Go To
Does not know address of new home	-2	ADULT_HH

SOURCE

National Children's Study, Legacy Phase (Pregnancy Screener)

(NEW_HOME_ST_NUM) Street Number:   _____________________

(NEW_HOME_ST_NAME) Street Name:  _____________________________________________

(NEW_HOME_UNIT)  Apartment/Unit Number:  ________________   

(NEW_HOME_CITY) City:  _____________________________________

(NEW_HOME_STATE) State:  l___l___l

(NEW_HOME_ZIP) Zip code:   l___l___l___l___l___l

(NEW_HOME_ZIP4_1)  

- l___l___l___l___l

           +4

PIU12000/(ADULT_HH). Is there another adult who lives with you in your household? 

Label	Code	Go To
Yes	1
No	2	OTHER_CONTACT

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

PIU13000. What is his/her first and last name?  If you live with more than one other adult, please choose the one who will always know how to get in touch with you. 

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

(PERS_FNAME) First Name: _____________________________________

(PERS_LNAME) Last Name:  _________________________________________________

PIU14000/(PERS_AGE). What is his/her age?

 

l___l___l

Age in years  

Label	Code	Go To
Don't Know	-1

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

PIU15000/(PERS_REL). What is your relationship to this adult?  Are you his/her…

Label	Code	Go To
Biological mother	2
Biological father	4
Spouse	6
Partner/Significant Other	7
Child	8
Sibling	9
Grandparent	10
Other Relative	11
Friend	12
Co-Worker	14
Caregiver	15
Teacher	16
Aunt	19
Uncle	20
Cousin	21
Other Non-Relative	22
Adoptive Mother	23
Adoptive Father	24
Social Mother	25
Social Father	26
Step Mother	27
Step Father	28
Step Brother	29
Step Sister	30
Adoptive Brother	31
Adoptive Sister	32
Grandmother	33
Grandfather	34

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

PIU16000/(PERS_CELL_NUM). What is his/her cell phone number?

 

________________________________________

Label	Code	Go To
Does not have a cell phone	-1

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

PIU17000/(PERS_EMAIL). What is his/her email address?

 

________________________________________________

Label	Code	Go To
Does not have an email address	-1

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

PIU18000/(OTHER_CONTACT). Is there a relative or friend, who does not live in your household, who will always know how to reach you?  We will only contact this person if we cannot find you to schedule your next Study Visit.  

Label	Code	Go To
Yes	1
No	2	PIU25000

SOURCE

New

PIU19000. What is his/her first and last name? 

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

(OTHER_CONT_FNAME)  First Name: ___________________________________________

(OTHER_CONT_LNAME) Last Name:___________________________________________

PIU20000/(OTHER_CONT_AGE). What is his/her age? 

 

l___l___l

Age in years                                                                                                  

Label	Code	Go To
Don't Know	-1

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

PIU21000/(OTHER_CONT_REL). What is your relationship to this person?  Are you his/her… 

Label	Code	Go To
Biological Mother	2
Biological Father	4
Spouse	6
Partner/Significant Other	7
Child	8
Sibling	9
Grandparent	10
Other Relative	11
Friend	12
Co-Worker	14
Caregiver	15
Teacher	16
Aunt	19
Uncle	20
Cousin	21
Other Non-Relative	22
Adoptive Mother	23
Adoptive Father	24
Social Mother	25
Social Father	26
Step Mother	27
Step Father	28
Step Brother	29
Step Sister	30
Adoptive Brother	31
Adoptive Sister	32
Grandmother	33
Grandfather	34

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

PIU22000/(OTHER_CONT_CELL). What is his/her cell phone number?

 

________________________________________

Label	Code	Go To
Does not have a cell phone	-1

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

PIU23000/(OTHER_CONT_HOME). What is his/her home phone number?

 

____________________________________________

Label	Code	Go To
Does not have a home phone/land line	-1

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

PIU24000/(OTHER_CONT_EMAIL). What is his/her email address?

 

___________________________________________

Label	Code	Go To
Does not have an email address	-1

SOURCE

Saving for Education, Entrepreneurship and Down payment for Oklahoma Kids (SEED) (modified)

PIU25000. Thank you for your dedication to the National Children’s Study.  Please place your completed survey in the postage-paid envelope and drop off at any mailbox. 

 

If you have any questions or concerns about this survey or the National Children’s Study, please call us at [INSERT TOLL-FREE ROC NUMBER]. 

PROGRAMMER INSTRUCTIONS

• INSERT TOLL-FREE ROC NUMBER.

FOR OFFICE USE ONLY

FOU01000/(P_ID). Participant ID:___________________________________

FOU02000/(R_P_ID). Respondent ID:________________________________

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.