Form 40.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Noise Measurement SAQ, Phase 2g

OMB Specification

Noise Measurement SAQ

Event Category:	Time-Based
Event:	36M, 60M
Administration:	N/A
Instrument Target:	Child's Primary Residence
Instrument Respondent:	Primary Caregiver
Domain:	Environmental
Document Category:	Sample Collection
Method:	Self-Administered
Mode (for this instrument*):	In-Person, PAPI
OMB Approved Modes:	In-Person, PAPI; Phone, PAPI; Web-Based, CAI
Estimated Administration Time:	9 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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Noise Measurement SAQ

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

ENVIRONMENTAL NOISE MEASUREMENT SAQ SPECIFICATION 3

FOR DATA COLLECTOR USE ONLY: 8

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Noise Measurement 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.

ENVIRONMENTAL NOISE MEASUREMENT SAQ SPECIFICATION

ENM00000. Please use a black or blue pen to complete this form.  Do not use a felt-tip pen or pencil.

Mark X to indicate your answer.

If you want to change your answer, mark through the box on the wrong answer, and mark the correct answer.

Your answers are important.  Please print clearly using uppercase, block letters (for example, “WEDNESDAY”).

Follow the instructions in your booklet when completing this questionnaire.

ENM01000. Enter the date you took down the noise monitor.

SOURCE

New

(NOISE_REMOVE_MM) |___|___|

   M    M

(NOISE_REMOVE_DD) |___|___|

   D     D

(NOISE_REMOVE_YYYY) 2 0 |___|___|

Y  Y  Y      Y

ENM02000/(NOISE_REMOVE_DAY). Mark the day of the week you took down the noise monitor.

Label	Code	Go To
Monday	1
Tuesday	2
Wednesday	3
Thursday	4
Friday	5
Saturday	6
Sunday	7

SOURCE

New

ENM03000. Enter the time you took down the noise monitor. 

SOURCE

New

(NOISE_REMOVE_TIME) TIME: |___|___| : |___|___|

            H     H         M     M

(NOISE_REMOVE_TIME_UNIT)

Label	Code	Go To
AM	1
PM	2

ENM04000/(NOISE_STAND_MOVED). Was the noise monitor stand moved during the measurement period?

Label	Code	Go To
Yes	1
No	2	NOISE_WINDOW_OPEN
Don't Know	-2	NOISE_STAND_ROOM

SOURCE

New

ENM05000/(NOISE_STAND_MOVED_ROOMS). Was the noise monitor stand moved to a different room from where it was set up?

Label	Code	Go To
Yes	1
No	2	NOISE_MICROPHONE_WALL

SOURCE

New

ENM06000/(NOISE_STAND_ROOM). Mark the room type where you took down the noise monitor.

Label	Code	Go To
A child’s bedroom	1	NOISE_CHILD_SHARE_ROOM
A common living area	2	NOISE_WINDOWS_FACE
An adult’s bedroom	3	NOISE_WINDOWS_FACE
Other	-5

SOURCE

New

ENM07000/(NOISE_STAND_ROOM_OTH). SPECIFY: ________________________________________

SOURCE

New

PARTICIPANT INSTRUCTIONS

Go to ENM09000.

ENM08000/(NOISE_CHILD_SHARE_ROOM). Does the child share the bedroom with any other family member(s)?

Label	Code	Go To
Yes	1
No	2

SOURCE

New

ENM09000/(NOISE_WINDOWS_FACE). Mark where the window(s) in the room face. Please check all that apply.

Label	Code	Go To
No window in room	1
Street with light traffic	2
Street with heavy traffic	3
Freeway or highway	4
Yard, garden, greenbelt, courtyard	5
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you selected "other" or any combination of responses and "other," go to ENM10000.

• If you did not select "other," go to ENM11000.

ENM10000/(NOISE_WINDOWS_FACE_OTH). SPECIFY: _________________________________________________________

SOURCE

New

ENM11000/(NOISE_MICROPHONE_WALL). Mark the approximate distance of the noise monitor microphone from the wall.

Label	Code	Go To
Less than 2 feet from the wall	1
2 or more feet from the wall	2

SOURCE

New

ENM12000/(NOISE_MICROPHONE_FLOOR). Mark the approximate height of the noise monitor microphone from the floor.

Label	Code	Go To
Less than 3 feet from the floor	1
3 or more feet from the wall	2

SOURCE

New

ENM13000/(NOISE_WINDOW_OPEN). Was/were the window(s) in the room open any time during the measurement period?

Label	Code	Go To
Yes	1
No	2

SOURCE

New

ENM14000/(NOISE_PROBLEMS). Were there any problems with the noise monitoring? Please check all that apply.

Label	Code	Go To
No problems	1
Needed to move the stand	2
Equipment damaged	3
Stand unlocked	4
Supplies missing	5
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you selected "other" or any combination of responses and "other," go to ENM15000.

• If you did not select "other," go to ENM16000.

ENM15000/(NOISE_PROBLEMS_OTH). SPECIFY: ________________________________________________________

SOURCE

New

ENM16000/(NOISE_SHIPPING_PROB). Were there any problems shipping the noise stand? Please check all that apply.

Label	Code	Go To
No problems	1
Shipping supplies missing	2
Other	-5

SOURCE

New

PARTICIPANT INSTRUCTIONS

• If you selected "other" or any combination of responses and "other," go to NOISE_SHIPPIN_PROB_OTH.

• If you did not select "other," go to NOISE_COMMENTS.

ENM17000/(NOISE_SHIPPING_PROB_OTH). (SPECIFY): _________________________________________________________

SOURCE

New

ENM1800/(NOISE_COMMENTS). Enter any comments about the noise measurement in your home.

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

SOURCE

New

ENM19000. Thank you very much for completing this questionnaire! All of your answers are very important.

Please help us by looking at each question again to make sure you:

Did not incorrectly skip any questions, and
Marked out the wrong answer and marked the right answer if you made changes.

Place this questionnaire in a resealable plastic bag and ship it with the noise monitor stand to the following address: [Include the shipping address here]

If you have any questions about the noise measurement in your home and/or shipping the noise monitor, please contact us at: [Include ROC contact information (phone number, email address, etc.) here.]

FOR DATA COLLECTOR USE ONLY:

FDC01000/(NOISE_EQUIP_ID). Equipment ID of the noise monitor

Equipment ID: ____________________________

FDC02000/(NOISE_SHIP_NUM). Shipment tracking number: ________________________________________

FDC03000/(STAFF_ID). Staff ID: _______________________________________

FDC04000/(R_P_ID). Respondent ID: _____________________________________

FDC05000/(P_ID). Participant ID: _________________________________________

Public reporting burden for this collection of information is estimated to average 9 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.