SEED- Care Giver Appendix B.2 , Appendix B.1

The Study to Explore Early Development (SEED)

Appendix B 2 Care Giver Interview

SEED- Care Giver Appendix B.2 , Appendix B.1

OMB: 0920-0741

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ID NUMBER:

Form Approved

OMB NO. __________

Exp. Date __________








National CADDRE Study:

Child Development and Autism


Primary Caregiver Interview



September 2006



Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 60 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)



TABLE OF CONTENTS




SECTION A: PRELIMINARY INFORMATION A-1

SECTION B: SOCIODEMOGRAPHICS B-1

SECTION C: MATERNAL REPRODUCTIVE AND PREGNANCY HISTORY C-1

SECTION D: INDEX PREGNANCY D-1

ASSISTED REPRODUCTION D-10

MORNING SICKNESS D-15

PRENATAL CARE D-17

BLOOD TESTS D-19

VAGINAL DOUCHING D-24

SECTION E: MATERNAL MEDICAL CONDITIONS, SURGERIES, PROCEDURES, AND MEDICATION USE E-1

REPRODUCTIVE AND MAJOR PERINATAL INFECTIONS AND CONDITIONS E-1

ORAL/DENTAL DISEASE E-8

INJURIES E-12

SURGERY E-16

OTHER PROCEDURES E-18

MEDICATION USE E-20

VACCINATIONS E-28

SECTION F: OBSTETRIC AND DELIVERY COMPLICATIONS F-1

OBSTETRIC COMPLICATIONS F-1

DELIVERY COMPLICATIONS F-8

SECTION G: POSTNATAL HISTORY G-1

MEDICAL CONDITIONS G-1

ALLERGIES G-4

MEDICATION USE G-6

INJURIES G-10

SECTION H: OCCUPATIONAL HISTORY H-1

SECTION J: TOBACCO, ALCOHOL, AND OTHER DRUGS J-1

TOBACCO J-1

ALCOHOL J-4

OTHER DRUGS J-5

SECTION K: INCOME AND CLOSING K-1

SECTION L: INTERVIEWER STATUS L-1

SECTION M: INTERVIEWER REMARKS M-1


SECTION A: PRELIMINARY INFORMATION


TIME STARTED :




RECORD IN MILITARY TIME.

INTERVIEWER NOTE: A1-A5 should be collected in the CIS during the follow-up/scheduling phone call. If the information is not available prior to this interview, and/or if the CIS is not available, ask A1*-A5* in the box below. Otherwise, confirm information using A1-A5 following the box.









A1*.

I would like to begin by asking you some basic questions. What is your full name?


FIRST NAME:

MIDDLE NAME:

LAST NAME:

SUFFIX:

MAIDEN NAME:





A2*.

What is your date of birth?


DOB - -

MM DD YYYY





A3*.

What is (CHILD)’s full name?


FIRST NAME:

MIDDLE NAME:

LAST NAME:

SUFFIX:





A4*.

What is (CHILD)’s date of birth? RECORD DATE HERE AND ON PREGNANCY REFERENCE FORM.


DOIB - -

MM DD YYYY





A5*.

What is your relationship to (CHILD)?


BIOLOGICAL MOTHER 01

BIOLOGICAL FATHER 02

STEP MOTHER 03

STEP FATHER 04

MATERNAL GRANDMOTHER 05

MATERNAL GRANDFATHER 06

PATERNAL GRANDMOTHER 07

PATERNAL GRANDFATHER 08

BROTHER 09

SISTER 10

AUNT 11

UNCLE 12

OTHER (SPECIFY) 90

SPECIFY:





PROGRAMMER NOTE: CATI Should automatically fill in child’s first name everywhere (CHILD) is listed in the interview.





A1.

I would like to begin by confirming some basic information about you and (CHILD). Is your full name (FULL NAME FROM CIS)?


YES 01

NO (UPDATE IN CIS) 02





A2.

Is your date of birth (MM/DD/YYYY DOB FROM CIS)?


YES 01

NO (UPDATE IN CIS) 02





A3.

Is (CHILD)’s full name (CHILD’S FULL NAME FROM CIS)?


YES 01

NO (UPDATE IN CIS) 02






A4.

Is (CHILD)’s date of birth (MM/DD/YYYY DOIB FROM CIS)?


YES 01

NO (UPDATE IN CIS) 02





A5.

Are you (CHILD)’s (RELATIONSHIP FROM CIS)?


YES 01

NO (UPDATE IN CIS) 02






During the interview, occasionally I’ll ask you to refer to the booklet you received in the mail labeled “Caregiver Interview Prep Guide.”





A6.

Did you read the prep guide?


YES 01

NO 02

RF 98

DK 99





A7.

Do you have the guide in front of you now?


YES (SKIP TO B1) 01

NO 02

RF 98

DK 99






The interview will go much faster if you have the Guide in front of you. I will wait while you find it. If you cannot find the guide or you lost it, I will ask some of the questions in more detail. This could add as much as an hour to the time it takes to complete the interview.







SECTION B: SOCIODEMOGRAPHICS







PROGRAMMER NOTE: Depending on who R is, different parts of Section B will be administered:



If R is BioMom (A5=01), ask B2-B11 about BioMom, B12, and B13-B23 about BioDad (if known). Skip B24-B33.



If R is BioDad (A5=02), ask alternative B1-B11 questions about BioMom and alternative B14-B23 questions about BioDad. Skip B24-B33.



If R is not BioMom or BioDad (A5=03–90), ask alternative B1-B11 questions about BioMom and B12-B23 questions about BioDad. Ask B24-B33 about R.



Ask B34-B45 if R has a spouse/partner/other caregiver in home who is not BioMom or BioDad.



CATI should adjust to alternative wording as indicated.






I am going to ask you some basic questions about (your/[CHILD]’s biological mother’s) family background and education.






IF R IS BIOMOM (A5=01), SKIP TO B2.


­





B1.

What is (CHILD)’s biological mother’s birthdate?


DOB - -

MM DD YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999





B2.

(Were you/Was [CHILD]’s biological mother) born in the US?


YES (SKIP TO B6) 01

NO 02

RF (SKIP TO B6) 98

DK (SKIP TO B6) 99





B3.

What country (were you/was she) born in?


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99





B4.

What year did (you/she) come to the US to live?


YEAR (SKIP TO B6)

N/A (SKIP) 9997

RF (SKIP TO B6) 9998

DK 9999





B5.

How old (were you/was she) when (you/she) came to the US to live?


AGE IN YEARS

N/A (SKIP) 97

RF 98

DK 99






B6.

What language (do you/does she) usually speak at home?


ENGLISH 01

SPANISH 02

OTHER (SPECIFY) 90

RF 98

DK 99


SPECIFY:





PROGRAMMER NOTE: CATI should be able to capture multiple categories for multiracial participants. RF and DK cannot be combined with other answers.





B7.

What is (your/her) race or ethnic group? I’m going to read you a list and then please tell me all categories that apply to (you/her). You can select more than one category. READ ANSWERS AND CODE ALL THAT APPLY.


American Indian or Alaska Native (ASK A) 01

Asian (ASK B) 02

Black or African American 03

Hispanic or Latina (ASK B8) 04

Native Hawaiian or Other Pacific Islander (ASK B) 05

White 06

RF (SKIP TO B9) 98

DK (SKIP TO B9) 99






IF B7 INCLUDES CODE 01, ASK B7A. OTHERWISE, SKIP TO B7B.






A. What tribe (do you/does she) consider (yourself/herself) a member of?


TRIBE:

N/A (SKIP) 97

RF 98

DK 99






IF B7 INCLUDES CODE 02 OR 05, ASK B7B. OTHERWISE, SKIP TO B8.






B. What is your country of ethnic origin? (PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.)


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99






IF B7 INCLUDES CODE 04, ASK B8. OTHERWISE, SKIP TO B9.





B8.

Which Hispanic or Spanish group (do you consider yourself/does she consider herself) a member of? (PROMPT: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc.?)


GROUP:

N/A (SKIP) 97

RF 98

DK 99






B9.

What was the highest grade or year of school or college that (you/she) had completed at the time (CHILD) was born? READ LIST. SELECT ONE.


No formal schooling 01

Less than high school (ASK A) 02

12 years, completed high school or equivalent 03

1-3 Years of college 04

Completed technical college 05

Associate’s degree 06

4 years of college or bachelor’s degree 07

Master’s degree 08

Advanced degree 09

RF 98

DK 99






IF B9 NOT EQUAL TO 02, SKIP TO B10.






A. How many years of school did (you/she) complete?


# OF YEARS

N/A (SKIP) 97

RF 98

DK 99





B10.

Is that the highest grade or year of school or college (you have/she has) currently completed?


YES (SKIP TO B12) 01

NO 02

RF (SKIP TO B12) 98

DK (SKIP TO B12) 99





B11.

What is the highest grade or year of school or college that (you have/she has) currently completed? READ LIST. SELECT ONE.


Less than high school (ASK A) 02

12 years, completed high school or equivalent 03

1-3 Years of college 04

Completed technical college 05

Associate’s degree 06

4 years of college or bachelor’s degree 07

Master’s degree 08

Advanced degree 09

N/A (SKIP) 97

RF 98

DK 99






IF B11 NOT EQUAL TO 02, SKIP TO B12.






A. How many years of school did (you/she) complete?


# OF YEARS

N/A (SKIP) 97

RF 98

DK 99







IF R IS BIODAD (A5=02), SKIP TO B14.





B12.

The next few questions are about (CHILD)’s biological father. If you do not know (CHILD)’s father, please let me know at this time.


DK FATHER (SKIP TO B24) 01

KNOWS FATHER 02

N/A (SKIP) 97

RF (SKIP TO B24) 98





PROGRAMMER NOTE: If respondent doesn’t know CHILD’s bio father, all questions in the remaining interview about the father should be flagged so that the interviewer will know not to ask those questions.





B13.

What is (CHILD)’s biological father’s birthdate?


DOB - -

MM DD YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999






IF R IS BIODAD (A5=02), READ: The next few questions are about your family background and education.





B14.

(Was he/Were you) born in the US?


YES (SKIP TO B18) 01

NO 02

N/A (SKIP) 97

RF (SKIP TO B18) 98

DK (SKIP TO B18) 99





B15.

What country (was he/were you) born in?


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99





B16.

What year did (he/you) come to the US to live?


YEAR (SKIP TO B18)

N/A (SKIP) 9997

RF (SKIP TO B18) 9998

DK 9999





B17.

How old (was he/were you) when (he/you) came to the US to live?


AGE IN YEARS

N/A (SKIP) 97

RF 98

DK 99





B18.

What language (does he/do you) usually speak at home?


ENGLISH 01

SPANISH 02

OTHER (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:


B19.

What is (his/your) race or ethnic group? I’m going to read you a list and then please tell me all categories that apply to (him/you). You can select more than one category. READ ANSWERS AND CODE ALL THAT APPLY.


American Indian or Alaska Native (ASK A) 01

Asian (ASK B) 02

Black or African American 03

Hispanic or Latino (ASK B20) 04

Native Hawaiian or Other Pacific Islander (ASK B) 05

White 06

RF (SKIP TO B21) 98

DK (SKIP TO B21) 99






IF B19 INCLUDES CODE 01, ASK B19A. OTHERWISE, SKIP TO B19B.






A. What tribe (does he/do you) consider (himself/yourself) a member of?


TRIBE:

N/A (SKIP) 97

RF 98

DK 99






IF B19 INCLUDES CODE 02 OR 05, ASK B19B. OTHERWISE, SKIP TO B20.






B. What is your country of ethnic origin? (PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.)


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99






IF B19 INCLUDES CODE 04, ASK B20. OTHERWISE, SKIP TO B21.





B20.

Which Hispanic or Spanish group (does he consider himself/do you consider yourself) a member of? (PROMPT: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc.?)


GROUP:

N/A (SKIP) 97

RF 98

DK 99





B21.

What was the highest grade or year of school or college that ([CHILD]’s father/you) had completed at the time (CHILD) was born? READ LIST. SELECT ONE.


No formal schooling 01

Less than high school (ASK A) 02

12 years, completed high school or equivalent 03

1-3 Years of college 04

Completed technical college 05

Associate’s degree 06

4 years of college or bachelor’s degree 07

Master’s degree 08

Advanced degree 09

N/A (SKIP) 97

RF 98

DK 99



IF B21 NOT EQUAL TO 02, SKIP TO B22.






A. How many years of school did (he/you) complete?


# OF YEARS

N/A (SKIP) 97

RF 98

DK 99





B22.

Is that the highest grade or year of school or college (he has/you have) currently completed?


YES (SKIP TO B24) 01

NO 02

N/A (SKIP) 97

RF (SKIP TO B24) 98

DK (SKIP TO B24) 99





B23.

What is the highest grade or year of school or college that (he has/you have) currently completed? READ LIST. SELECT ONE.


Less than high school (ASK A) 02

12 years, completed high school or equivalent 03

1-3 Years of college 04

Completed technical college 05

Associate’s degree 06

4 years of college or bachelor’s degree 07

Master’s degree 08

Advanced degree 09

N/A (SKIP) 97

RF 98

DK 99






IF B23 NOT EQUAL TO 02, SKIP TO B24.






A. How many years of school did (he/you) complete?


# OF YEARS

N/A (SKIP) 97

RF 98

DK 99






IF R IS BIOMOM OR BIODAD (A5=01 OR 02), SKIP TO B34.






The next few questions are about your family background and education.





B24.

Were you born in the US?


YES (SKIP TO B28) 01

NO 02

N/A (SKIP) 97

RF (SKIP TO B28) 98

DK (SKIP TO B28) 99





B25.

What country were you born in?


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99






B26.

What year did you come to the US to live?


YEAR (SKIP TO B28)

N/A (SKIP) 9997

RF (SKIP TO B28) 9998

DK 9999





B27.

How old were you when you came to the US to live?


AGE IN YEARS

N/A (SKIP) 97

RF 98

DK 99





B28.

What language do you usually speak at home?


ENGLISH 01

SPANISH 02

OTHER (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:





B29.

What is your race or ethnic group? I’m going to read you a list and then please tell me all categories that apply to you. You can select more than one category. READ ANSWERS AND CODE ALL THAT APPLY.


American Indian or Alaska Native (ASK A) 01

Asian (ASK B) 02

Black or African American 03

Hispanic or (Latina/Latino) (ASK B30) 04

Native Hawaiian or Other Pacific Islander (ASK B) 05

White 06

RF (SKIP TO B31) 98

DK (SKIP TO B31) 99






IF B29 INCLUDES CODE 01, ASK B29A. OTHERWISE, SKIP TO B29B.






A. What tribe do you consider yourself a member of?


TRIBE:

N/A (SKIP) 97

RF 98

DK 99






IF B29 INCLUDES CODE 02 OR 05, ASK B29B. OTHERWISE, SKIP TO B30.






B. What is your country of ethnic origin? (PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.)


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99



IF B29 INCLUDES CODE 04, ASK B30. OTHERWISE, SKIP TO B31.





B30.

Which Hispanic or Spanish group do you consider yourself a member of? (PROMPT: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc.?)


GROUP:

N/A (SKIP) 97

RF 98

DK 99





B31.

What was the highest grade or year of school or college that you had completed at the time (CHILD) was born? READ LIST. SELECT ONE.


No formal schooling 01

Less than high school (ASK A) 02

12 years, completed high school or equivalent 03

1-3 Years of college 04

Completed technical college 05

Associate’s degree 06

4 years of college or bachelor’s degree 07

Master’s degree 08

Advanced degree 09

N/A (SKIP) 97

RF 98

DK 99






IF B31 NOT EQUAL TO 02, SKIP TO B32.






A. How many years of school did you complete?


# OF YEARS

N/A (SKIP) 97

RF 98

DK 99





B32.

Is that the highest grade or year of school or college you have currently completed?


YES (SKIP TO B34) 01

NO 02

N/A (SKIP) 97

RF (SKIP TO B34) 98

DK (SKIP TO B34) 99





B33.

What is the highest grade or year of school or college that you have currently completed? READ LIST. SELECT ONE.


Less than high school (ASK A) 02

12 years, completed high school or equivalent 03

1-3 Years of college 04

Completed technical college 05

Associate’s degree 06

4 years of college or bachelor’s degree 07

Master’s degree 08

Advanced degree 09

N/A (SKIP) 97

RF 98

DK 99






IF B33 NOT EQUAL TO 02, SKIP TO B34.






A. How many years of school did you complete?


# OF YEARS

N/A (SKIP) 97

RF 98

DK 99


The next few questions are about the family background and education of any other caregivers living in the home with (CHILD).





B34.

Do you live with a spouse or partner or other adult who is a primary caregiver of (CHILD) who is not (CHILD)’s biological parent?


YES 01

NO (SKIP TO NEXT SECTION) 02

RF (SKIP TO NEXT SECTION) 98

DK (SKIP TO NEXT SECTION) 99






A. What is that person’s relationship to (CHILD)?


STEPMOTHER 01

STEPFATHER 02

MATERNAL GRANDMOTHER 03

MATERNAL GRANDFATHER 04

PATERNAL GRANDMOTHER 05

PATERNAL GRANDFATHER 06

BROTHER 07

SISTER 08

AUNT 09

UNCLE 10

MOM’S PARTNER 11

DAD’S PARTNER 12

OTHER (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:





B35.

What is (CAREGIVER)’s birthdate?


DOB - -

MM DD YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999





B36.

Was (CAREGIVER) born in the US?


YES (SKIP TO B40) 01

NO 02

N/A (SKIP) 97

RF (SKIP TO B40) 98

DK (SKIP TO B40) 99





B37.

What country was (CAREGIVER) born in?


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99





B38.

What year did (CAREGIVER) come to the US to live?


YEAR (SKIP TO B40)

N/A (SKIP) 9997

RF (SKIP TO B40) 9998

DK 9999





B39.

How old was (CAREGIVER) when (he/she) came to the US to live?


AGE IN YEARS

N/A (SKIP) 97

RF 98

DK 99






B40.

What language does (CAREGIVER) usually speak at home?


ENGLISH 01

SPANISH 02

OTHER (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:





B41.

What is (CAREGIVER)’s race or ethnic group? I’m going to read you a list and then please tell me all categories that apply to (him/her). You can select more than one category. READ ANSWERS AND CODE ALL THAT APPLY.


American Indian or Alaska Native (ASK A) 01

Asian (ASK B) 02

Black or African American 03

Hispanic or (Latina/Latino) (ASK B42) 04

Native Hawaiian or Other Pacific Islander (ASK B) 05

White 06

RF (SKIP TO B43) 98

DK (SKIP TO B43) 99






IF B41 INCLUDES CODE 01, ASK B41A. OTHERWISE, SKIP TO B41B.










A. What tribe does (he/she) consider (himself/herself) a member of?


TRIBE:

N/A (SKIP) 97

RF 98

DK 99






IF B41 INCLUDES CODE 02 OR 05, ASK B41B. OTHERWISE, SKIP TO B42.






B. What is (his/her) country of ethnic origin? (PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.)


COUNTRY:

N/A (SKIP) 97

RF 98

DK 99






IF B41 INCLUDES CODE 04, ASK B42. OTHERWISE, SKIP TO B43.





B42.

Which Hispanic or Spanish group (does (he/she) consider (himself/herself) a member of? (PROMPT: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc.?)


GROUP:

N/A (SKIP) 97

RF 98

DK 99






B43.

What was the highest grade or year of school or college that (CAREGIVER) had completed at the time (CHILD) was born? READ LIST. SELECT ONE.


No formal schooling 01

Less than high school (ASK A) 02

12 years, completed high school or equivalent 03

1-3 Years of college 04

Completed technical college 05

Associate’s degree 06

4 years of college or bachelor’s degree 07

Master’s degree 08

Advanced degree 09

N/A (SKIP) 97

RF 98

DK 99






IF B43 NOT EQUAL TO 02, SKIP TO B44.






A. How many years of school did (he/she) complete?


# OF YEARS

N/A (SKIP) 97

RF 98

DK 99





B44.

Is that the highest grade or year of school or college (he/she) has currently completed?


YES (SKIP TO NEXT SECTION) 01

NO 02

N/A (SKIP) 97

RF (SKIP TO NEXT SECTION) 98

DK (SKIP TO NEXT SECTION) 99





B45.

What is the highest grade or year of school or college that (CAREGIVER) has currently completed? READ LIST. SELECT ONE.


Less than high school (ASK A) 02

12 years, completed high school or equivalent 03

1-3 Years of college 04

Completed technical college 05

Associate’s degree 06

4 years of college or bachelor’s degree 07

Master’s degree 08

Advanced degree 09

N/A (SKIP) 97

RF 98

DK 99






IF B45 NOT EQUAL TO 02, SKIP TO NEXT SECTION.






A. How many years of school did (he/she) complete?


# OF YEARS

N/A (SKIP) 97

RF 98

DK 99




















BLANK PAGE FOR END OF SECTION

IF R IS NOT BIOMOM (A5>01), SKIP TO SECTION G.



SECTION C: MATERNAL REPRODUCTIVE AND PREGNANCY HISTORY





C1.

Now I’m going to ask you some questions about your reproductive and pregnancy experiences. How old were you when you had your first menstrual period?


AGE IN YEARS (SKIP TO C2)

RF (SKIP TO C2) 98

DK 99






A. What grade were you in when you had your first menstrual period?


GRADE

N/A (SKIP) 97

RF 98

DK 99





C2.

Before you were pregnant with (CHILD), what was the average or typical number of days of your cycle from the first day of one menstrual period through the first day of the next menstrual period? Please think back to a time when you were not using birth control pills or other hormonal contraceptives.


# OF DAYS

IRREGULAR PERIOD 90

RF 98

DK 99





C3.

How many times have you been pregnant? Please count all pregnancies, including those that ended in live birth, stillbirth, miscarriage, abortion, or a tubal, ectopic, or molar pregnancy. Include pregnancies from other relationships and your pregnancy with (CHILD).


# OF PREGNANCIES

RF 98

DK 99





C4.

How many babies were you carrying during your (1st/2nd/3rd) pregnancy? (PROBE: Did you have a single baby, twins, or more babies?)






ANSWER C4 FOR EACH PREGNANCY, THEN TOTAL NUMBER OF BABIES. IF R REPORTS ZERO OR DK, ADD 1 TO BABY COUNT. IF R REFUSES NUMBER OF BABIES, DO NOT INCLUDE IN COUNT.







# OF BABIES

N/A (SKIP)

RF

DK


PREGNANCY 1


98

99


PREGNANCY 2

97

98

99


PREGNANCY 3

97

98

99


PREGNANCY 4

97

98

99


PREGNANCY 5

97

98

99


PREGNANCY 6

97

98

99


PREGNANCY 7

97

98

99


PREGNANCY 8

97

98

99


BABY COUNT


98





(IF ALL PREGS=RF, SKIP TO C18)



NUMBER OF BABIES/PREGNANCY SUPPLEMENTS


IF C3 = 1 AND C4 = 1, READ: This baby must be (CHILD). CODE C5 = 1 AND C6 = 1, AND SKIP TO C10. OTHERWISE, READ: I would now like to ask you a few questions about the outcomes of each of your pregnancies.





COMPLETE ONE ROW OF BABY TABLE (C5–C14) FOR EACH BABY.




C5.

C6.

C7.

C8.

C 9A.

BABY COUNT:

IF C4 = 0, 1 OR 99, READ: Was your (1st/2nd/3rd) pregnancy a (READ ANSWERS)? OTHERWISE, READ: Was the (1st/2nd/3rd) baby in your (1st/2nd/3rd) pregnancy a (READ ANSWERS)?

Is this baby (CHILD)?

What is the first name of this baby?

Is (BABY) a boy or girl?

What is (BABY)’s birthdate?

BABY:






1

Live birth 01

Stillbirth 02

Abortion 03

Miscarriage 04

Ectopic or tubal preg 05

Molar pregnancy 06

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99


N/A (SKIP) 97

RF 98

DK 99

BOY 01

GIRL 02

N/A (SKIP) 97

RF 98

DK 99

-

MM DD

YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999


IF C5 = 02-06, SKIP TO C9B. IF C5 = 98 OR 99, SKIP TO NEXT BABY/C15.

IF C6 = 01, CODE REMAINING C6 AS 02 AND SKIP TO C10.



SKIP TO C10.







2

Live birth 01

Stillbirth 02

Abortion 03

Miscarriage 04

Ectopic or tubal preg 05

Molar pregnancy 06

CURRENTLY PREGNANT 90

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99


N/A (SKIP) 97

RF 98

DK 99

BOY 01

GIRL 02

N/A (SKIP) 97

RF 98

DK 99

-

MM DD

YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999


IF C5=02-06, SKIP TO C9B; IF C5=90, SKIP TO C17; IF C5=98 OR 99, SKIP TO NEXT BABY/C15.

IF C6 = 01, CODE REMAINING C6 AS 02 AND SKIP TO C10.



SKIP TO C10.







3

Live birth 01

Stillbirth 02

Abortion 03

Miscarriage 04

Ectopic or tubal preg 05

Molar pregnancy 06

CURRENTLY PREGNANT 90

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99


N/A (SKIP) 97

RF 98

DK 99

BOY 01

GIRL 02

N/A (SKIP) 97

RF 98

DK 99

-

MM DD

YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999


IF C5=02-06, SKIP TO C9B; IF C5=90, SKIP TO C17; IF C5=98 OR 99, SKIP TO NEXT BABY/C15.

IF C6 = 01, CODE REMAINING C6 AS 02 AND SKIP TO C10.



SKIP TO C10.







4

Live birth 01

Stillbirth 02

Abortion 03

Miscarriage 04

Ectopic/tubal preg 05

Molar pregnancy 06

CURRENTLY PREGNANT 90

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99


N/A (SKIP) 97

RF 98

DK 99

BOY 01

GIRL 02

N/A (SKIP) 97

RF 98

DK 99

-

MM DD

YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999


IF C5=02-06, SKIP TO C9B; IF C5=90, SKIP TO C17; IF C5=98 OR 99, SKIP TO NEXT BABY/C15.

IF C6 = 01, CODE REMAINING C6 AS 02 AND SKIP TO C10.



SKIP TO C10.


C9B.

C10.

C11.

C12.

C 13A.

On what date did the pregnancy (for this baby) end?

How many pounds and ounces did (BABY) weigh?

Is (BABY) still living?

What did (BABY) die of? RECORD VERBATIM.

How old was (BABY) when (he/she) died?

BABY:





-

MM DD

YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999

LBS

OUNCES

OR GRAMS

OR KILOGRAMS .

N/A (SKIP) 9797

RF 9898

DK 9999

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

N/A (SKIP) 97

RF 98

DK 99

DAYS

MONTHS

YEARS

N/A (SKIP) 97 97

RF 98 98

DK 99 99

IF C5 = 02–04, SKIP TO C14. OTHERWISE, SKIP TO NEXT BABY/C15.

IF C6 = 01, SKIP TO C14.

IF C11 = 01, 98, OR 99, SKIP TO C14.


IF C13A NOT DK,
SKIP TO C14.






-

MM DD

YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999

LBS

OUNCES

OR GRAMS

OR KILOGRAMS .

N/A (SKIP) 9797

RF 9898

DK 9999

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

N/A (SKIP) 97

RF 98

DK 99

DAYS

MONTHS

YEARS

N/A (SKIP) 97 97

RF 98 98

DK 99 99

IF C5 = 02–04, SKIP TO C14. OTHERWISE, SKIP TO NEXT BABY/C15.

IF C6 = 01, SKIP TO C14.

IF C11 = 01, 98, OR 99, SKIP TO C14.


IF C13A NOT DK,
SKIP TO C14.






-

MM DD

YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999

LBS

OUNCES

OR GRAMS

OR KILOGRAMS .

N/A (SKIP) 9797

RF 9898

DK 9999

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

N/A (SKIP) 97

RF 98

DK 99

DAYS

MONTHS

YEARS

N/A (SKIP) 97 97

RF 98 98

DK 99 99

IF C5 = 02–04, SKIP TO C14. OTHERWISE, SKIP TO NEXT BABY/C15.

IF C6 = 01, SKIP TO C14.

IF C11 = 01, 98, OR 99, SKIP TO C14.


IF C13A NOT DK,
SKIP TO C14.






-

MM DD

YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999

LBS

OUNCES

OR GRAMS

OR KILOGRAMS .

N/A (SKIP) 9797

RF 9898

DK 9999

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

N/A (SKIP) 97

RF 98

DK 99

DAYS

MONTHS

YEARS

N/A (SKIP) 97 97

RF 98 98

DK 99 99

IF C5 = 02–04, SKIP TO C14. OTHERWISE, SKIP TO NEXT BABY/C15.

IF C6 = 01, SKIP TO C14.

IF C11 = 01, 98, OR 99, SKIP TO C14.


IF C13A NOT DK,
SKIP TO C14.


C13B.

C14.



What was the date of (BABY)’s death?

Now I will ask you about some developmental information a doctor or health care provider may have told you about your child. Please note that a health care provider at the child's school such as a child psychologist, physical therapist, occupational therapist, or school nurse should also be considered a qualified health care professional in answering these questions; however, the child's teachers should not be considered health care providers.


ASK R TO REFER TO LIST 1 IN PREP GUIDE. Has a doctor or health care provider ever told you that (BABY) had or has any of the conditions in list 1 in the prep guide? READ CHOICES BELOW IN CODE LIST. CODE ALL THAT APPLY.


IF C5 = 02–04, ONLY READ SHADED CODES.


-

MM DD


YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999

PROBLEM CODE(S):


SPECIFY:



CODE LIST

Asperger’s Syndrome 01

Attention Deficit Hyperactivity Disorder (ADHD) or ADD 02

Autism 03

Behavioral problem (SPECIFY) 04

Bipolar disorder 05

Birth Defects (SPECIFY) 06

Cerebral palsy 07

Childhood Disintegrative Disorder 08

Childhood onset schizophrenia 09

Developmental delay 10

Down Syndrome 11

Fragile X Syndrome 12

Hearing problems 13

Learning disabilities 14

Mental retardation 15

Movement or coordination problems 16

Neurofibromatosis 17

Obsessive compulsive disorder 18

Other developmental problem
(SPECIFY) 19

Pervasive Developmental Disorder
not otherwise specified 20

Reactive attachment disorder of infancy or early childhood 21

Reading difficulty 22

Rett’s Syndrome 23

Seizure disorder or Epilepsy 24

Self-injuring behavior 25

Sensory integration disorder 26

Sleep disorder 27

Speech delays 28

Tourette’s Disorder or tic disorder 29

Tuberous sclerosis 30

Vision problems that cannot be corrected with glasses or contact lenses 31

N/A (SKIP) 97

RF 98

DK 99


RETURN TO C5 FOR NEXT BABY.

FINAL INTERVIEWER CHECKS:

ONE ANSWER TO C6 MUST BE YES.

ASK: Did you have any other pregnancies that we did not discuss? IF YES, CHANGE C3. IF NO, CONTINUE WITH C15.





-

MM DD


YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999

PROBLEM CODE(S):


SPECIFY:







-

MM DD


YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999

PROBLEM CODE(S):


SPECIFY:







-

MM DD


YYYY

N/A (SKIP) 97 97 9997

RF 98 98 9998

DK 99 99 9999

PROBLEM CODE(S):


SPECIFY:





NUMBER OF BABY TABLE SUPPLEMENTS















UNFOLD PAGE FOR 3-PAGE TABLE

IF C3 = 1 AND C4 = 1, SKIP TO C18.







COMPLETE ONE ROW (C15–C17) FOR EACH PREGNANCY IN C3.





I have just a few more questions about each of your pregnancies.






IF C4 = 0, 1, OR 99, SKIP TO C17.

IF C4 = 2 AND C8 ANSWERS ARE DIFFERENT, SKIP TO C17.


IF C6 = 1, SKIP TO NEXT PREGNANCY/C18.






C15.

C16.

C17.


Were the babies in your (1st/2nd/3rd) pregnancy identical?

How do you know they (are/are not) identical? CODE ALL THAT APPLY.

Was the father of your (1st/2nd/3rd) pregnancy the same as (CHILD)’s father?

PREGNANCY:




1

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

DOCTOR TOLD YOU 01

GENETIC TESTS 02

THEY ARE AS ALIKE AS TWO PEAS IN A POD 03

THEY LOOK NOTHING ALIKE 04

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99


IF C15 = 98 OR 99, SKIP TO C17.







2

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

DOCTOR TOLD YOU 01

GENETIC TESTS 02

THEY ARE AS ALIKE AS TWO PEAS IN A POD 03

THEY LOOK NOTHING ALIKE 04

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99


IF C15 = 98 OR 99, SKIP TO C17.







3

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

DOCTOR TOLD YOU 01

GENETIC TESTS 02

THEY ARE AS ALIKE AS TWO PEAS IN A POD 03

THEY LOOK NOTHING ALIKE 04

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99


IF C15 = 98 OR 99, SKIP TO C17.







4

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

DOCTOR TOLD YOU 01

GENETIC TESTS 02

THEY ARE AS ALIKE AS TWO PEAS IN A POD 03

THEY LOOK NOTHING ALIKE 04

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99


IF C15 = 98 OR 99, SKIP TO C17.




NUMBER OF PREGNANCY TABLE SUPPLEMENTS



We are interested in any hormonal medications you might have taken during your lifetime for any reason other than to prevent pregnancy or to prevent a miscarriage during pregnancy.





C18.

Did a doctor or other medical provider ever prescribe hormonal medication for any reason other than to prevent pregnancy or to prevent a miscarriage during pregnancy?


YES 01

NO (SKIP TO D1) 02

RF (SKIP TO D1) 98

DK (SKIP TO D1) 99





C19.

What was the reason that the hormonal medication was prescribed? READ ANSWERS AND CODE ALL THAT APPLY.


To regulate your cycle 01

To jump-start puberty 02

Growth regulation 03

Acne 04

Thyroid functioning 05

To help become pregnant 06

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99



SPECIFY:


















BLANK PAGE FOR END OF SECTION



SECTION D: INDEX PREGNANCY



INTERVIEWER NOTE: TAKE OUT THE PREGNANCY REFERENCE FORM. IS IT COMPLETE?



IF YES:

Now I have some questions specific to the pregnancy with (CHILD). Many questions will require you to remember the time period from three months prior to conception through ([CHILD]’s birth/breastfeeding). I am going to confirm some important dates with you before I help you fill in your Pregnancy Reference Form from your prep guide. For the purpose of this study we need to use the dates your doctor gave you that we asked about on an earlier call.



I have (CHILD)’s date of birth as (DATE OF BIRTH FROM FORM). Is this correct? IF NO, CORRECT FORM.



I have (CHILD)’s due date as (EST. DUE DATE ON FORM.) This was BASED ON WHICH OPTION WAS USED TO CALCULATE EST. DUE DATE, READ THE CORRESPONDING BELOW ALOUD:



1. Given as an exact date

2. One of the dates given to you at your first prenatal visit

3. Based on your child’s date of birth since your child was born on time – meaning at 40 weeks or 9.5 months from last menstrual period

4. Based on your child’s date of birth since you did not know the due date.

5. Based on your child being born early by (# OF WEEKS FROM WORKSHEET)

6. Based on your child being born late by (# OF WEEKS FROM WORKSHEET)



LOOK ON PREGNANCY REFERENCE FORM, COMPARE DOB AND EDC TO SEE #OF DAYS/WEEKS THE CHILD WAS BORN EARLIER/LATER THAN THE DOB.



This would mean that your child was born X (days/weeks) (earlier/later) than the expected due date. Is this correct? IF NO, CORRECT FORM. I have to make some adjustments which may take a few minutes.



This would then make the time you were pregnant be approximately starting from your last menstrual period (READ DATE FROM FORM) to (READ DOB FROM FORM.) Is this correct? IF NO, CORRECT FORM. I have to make some adjustments which may take a few minutes.



This would then make the 3 months before you were pregnant with (CHILD) be approximately from (READ DATE FROM FORM) to (READ DATE FROM FORM). Is this correct? IF NO, CORRECT FORM. I have to make some adjustments which may take a few minutes.



IF ON THE FORM, BREASTFEEDING = 0, I have that you did not breastfeed (CHILD). Is that correct? IF NO, CORRECT FORM. I have to make some adjustments which may take a few minutes.



IF ON THE FORM, BREASTFEEDING > 0, I have that you breastfeed (CHILD) for (# OF DAYS/WEEKS/MONTHS BREASTFEEDING FROM FORM). Is that correct? IF NO, CORRECT FORM. I have to make some adjustments which may take a few minutes.



Now I am going to help you fill the time periods on your Pregnancy Reference Form.



IF NO: COMPLETE PREGNANCY REFERENCE FORM PACKET. FILL OUT FORM ALOUD.





READ DATES FROM EACH LINE OF THE FORM BEGINNING WITH: We will refer to the 3 months before you became pregnant as the pre-pregnancy months -3, -2, and -1. From what we’ve computed, the dates for -3 are… Your first trimester would then be months 1, 2, and 3 with dates of…



Do these time periods look correct to you? IF NO, ADJUST AS NEEDED. Thank you. We will begin using the Pregnancy Reference Form in a few minutes.






D1.

How old was (CHILD) when you first introduced solid food?


MONTHS

AND/OR

WEEKS

RF 98

DK 99





D2.

How much did you weigh before your pregnancy with (CHILD)?


LBS

OR

KG

RF 998

DK 999





D3a.

What is your height without your shoes?


FEET

INCHES

OR

M

CM

RF 998

DK 999

D3b

Overall, how much weight did you gain or lose during your pregnancy with (CHILD)?


LBS

OR

KG


GAINED 001

LOST 002

NO CHANGE 003

RF 998

DK 999





D4.

How far along were you when you found out you were pregnant with (CHILD)?


MONTHS

AND/OR

WEEKS

RF 98

DK 99



















PAGE INTENTIONALLY LEFT BLANK.



D5.

Please refer to the pregnancy reference form. Between (-3) and (DOIB/END BF) did you use any birth control pills or morning after pills?


YES 01

NO (SKIP TO D8) 02

RF (SKIP TO D8) 98

DK (SKIP TO D8) 99





D6.

ASK R TO REFER TO LIST 2 IN PREP GUIDE. What was the name of the pill? Any others? IF R CAN’T RECALL, READ CONTRACEPTIVES LISTED BELOW. Was it (READ LIST)? CODE ALL THAT APPLY.






Alesse 01

Brevicon 02

Demulen 03

Desogen 04

Estrostep 05

Levlen 06

Levlite 07

Levora 08

Loestrin 09

Lo/Ovral 10

Micronor 11

Mircette 12

Modicon 13

Necon 14

Nordette 15

Norethindrone 16

Norinyl 17

Nor-Q.D 18

Ortho-Cept 19

OrthoCyclen 20

Ortho-Novum 21

Ortho Tri-Cyclen 22

Ovcon 23

Ovral 24

Tri-Levlen 25

Tri-Norinyl 26

Triphasil 27

Trivora 28

Zovia 29

Other (SPECIFY IN GRID) 90

N/A (SKIP) 97

RF 98

DK 99



D7A.

D7B.

D7C.

COMPLETE ONE ROW FOR EACH PILL TAKEN.

Which months between (-3) and (DOIB/END BF) were you using (PILL)? Please refer to the Pregnancy Reference Form.

Would you say you were using the pill in the three months before you became pregnant, from (-3) to (-1)?

Would you say you were using the pill in your first trimester, from (1) to (3)?

PILL NAME:







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#1:

D7A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#2:

D7A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#3:

D7A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.




D15.

Please refer to the pregnancy reference form. Between (-3) and (DOIB/END BF) did you use any birth control pills or morning after pills?


YES 01

NO (SKIP TO D18) 02

RF (SKIP TO D18) 98

DK (SKIP TO D18) 99





D16.

What was the name of the pill? IF R CAN’T RECALL, ASK R TO REFER TO LIST 2 IN PREP GUIDE AND READ CONTRACEPTIVES LISTED BELOW. Was it (READ LIST)? Any others?






Alesse 01

Brevicon 02

Demulen 03

Desogen 04

Estrostep 05

Levlen 06

Levlite 07

Levora 08

Loestrin 09

Lo/Ovral 10

Micronor 11

Mircette 12

Modicon 13

N

IF R DID NOT BREASTFEED,
SKIP TO NEXT PILL/D8.

econ 14

Nordette 15

Norinyl 16

Nor-Q.D 17

Ortho-Cept 18

OrthoCyclen 19

Ortho0-Novum 20

Ortho Tri-Cyclen 21

Ovcon 22

Ovral 23

Tri-Levlen 24

Tri-Norinyl 25

Triphasil 26

Trivora 27

Zovia 28

Other (SPECIFY IN GRID) 29

N/A (SKIP) 97

RF 98

DK 99


D7D.

D7E.

D7F.

Would you say you were using the pill in your second trimester, from (4) to (6)?

Would you say you were using the pill in your third trimester, from (7) to (10)?

Would you say you were using the pill during the months you breastfed, from (DOIB/10) to (END BF)?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


# OF BIRTH CONTROL PILL SUPPLEMENTS


D8.

Between (-3) and (DOIB/END BF) did you use any other method of contraception to avoid getting pregnant?


YES 01

NO (SKIP TO D11) 02

RF (SKIP TO D11) 98

DK (SKIP TO D11) 99





D9.

ASK R TO REFER TO LIST 3 IN PREP GUIDE. What method of contraception were you using? If you used more than one type of contraception, please tell me all the ones that you used. READ METHODS LISTED BELOW. CODE ALL THAT APPLY.






Birth control patch or Ortho-Evra 01

Condoms, male or female 02

Depo-Provera 03

Diaphragm or cervical cap 04

Intrauterine device or IUD 05

Jelly, foam or suppositories, or other spermicide 06

Norplant 07

Rhythm or calendar method 08

Sponge 09

Tubal Ligation 10

Vaginal ring or Nuva Ring 11

Vasectomy 12

Withdrawal method 13

Other (SPECIFY IN GRID) 90

N/A (SKIP) 97

RF 98

DK 99



D10A.

D10B.

D10C.

COMPLETE ONE ROW FOR EACH METHOD USED.

Which months between (-3) and (DOIB/END BF) were you using (METHOD)? Please refer to the Pregnancy Reference Form.

Would you say you were using (METHOD) in the three months before you became pregnant, from (-3) to (-1)?

Would you say you were using (METHOD) in your first trimester, from (1) to (3)?

METHOD NAME:







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#1:

D10A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#2:

D10A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#3:

D10A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.




D15.

Please refer to the pregnancy reference form. Between (-3) and (DOIB/END BF) did you use any birth control pills or morning after pills?


YES 01

NO (SKIP TO D18) 02

RF (SKIP TO D18) 98

DK (SKIP TO D18) 99





D16.

What was the name of the pill? IF R CAN’T RECALL, ASK R TO REFER TO LIST 2 IN PREP GUIDE AND READ CONTRACEPTIVES LISTED BELOW. Was it (READ LIST)? Any others?






Alesse 01

Brevicon 02

Demulen 03

Desogen 04

Estrostep 05

Levlen 06

Levlite 07

Levora 08

Loestrin 09

Lo/Ovral 10

Micronor 11

Mircette 12

Modicon 13

N

IF R DID NOT BREASTFEED,
SKIP TO NEXT METHOD/D11.

econ 14

Nordette 15

Norinyl 16

Nor-Q.D 17

Ortho-Cept 18

OrthoCyclen 19

Ortho0-Novum 20

Ortho Tri-Cyclen 21

Ovcon 22

Ovral 23

Tri-Levlen 24

Tri-Norinyl 25

Triphasil 26

Trivora 27

Zovia 28

Other (SPECIFY IN GRID) 29

N/A (SKIP) 97

RF 98

DK 99


D10D.

D10E.

D10F.

Would you say you were using (METHOD) in your second trimester, from (4) to (6)?

Would you say you were using (METHOD) in your third trimester, from (7) to (10)?

Would you say you were using (METHOD) during the months you breastfed, from (DOIB/10) to (END BF)?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


# OF CONTRACEPTION METHOD SUPPLEMENTS



IF R USED CONTRACEPTION (EITHER D5 OR D8 = 01), SKIP TO D11B.







D11A.

Did you (READ ANSWERS)?


Stop using contraception to get pregnant with (CHILD) 01

Get pregnant with (CHILD) during an interruption in using contraception 02

Not use any contraception before this pregnancy 03

N/A (SKIP) 97

RF 98

DK 99








SKIP TO D12.





D11B.

Did you (READ ANSWERS)?


Stop using contraception to get pregnant with (CHILD) 01

Get pregnant with (CHILD) during an interruption in using contraception 02

Get pregnant with (CHILD) while consistently using contraception 03

N/A (SKIP) 97

RF 98

DK 99





D12.

Before getting pregnant with (CHILD), was there ever a time you had regular intercourse for a period of 12 months or more without using contraception and did not become pregnant?


YES 01

NO 02

RF 98

DK 99






IF FATHER UNKNOWN (B12 = 01), SKIP TO D14.







D13.

Was there ever a time you had regular intercourse for a period of 12 months or more with (CHILD)’s father without using contraception and did not become pregnant?


YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99





D14.

Before getting pregnant with (CHILD), were you trying to get pregnant?


YES 01

NO (SKIP TO D16) 02

RF (SKIP TO D16) 98

DK (SKIP TO D16) 99





D15.

How long had you been trying to get pregnant?


MONTHS

YEARS

N/A (SKIP) 97

RF 98

DK 98





D16.

Prior to becoming pregnant with (CHILD), had you ever been told by a doctor or other health care provider that it would be impossible for you to get pregnant without medical help?


YES 01

NO (SKIP TO D18) 02

RF (SKIP TO D18) 98

DK (SKIP TO D18) 99






D17.

Why were you told that it would be impossible for you to get pregnant without medical help? Was it because (READ ANSWERS AND CODE ALL THAT APPLY)?


Both of your ovaries were missing or removed 01

Both of your fallopian tubes were missing or removed 02

You had a tubal sterilization. For example, you had your tubes tied or clamped 03

Some other reason (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:





D18.

Prior to becoming pregnant with (CHILD), had you ever been told by a doctor or other health care provider that it might be difficult for you to get pregnant without medical help?


YES 01

NO (SKIP TO D21) 02

RF (SKIP TO D21) 98

DK (SKIP TO D21) 99





D19.

Were you ever told by a doctor or health care provider that you had (READ ANSWERS AND CODE ALL THAT APPLY)?


Blocked or damaged fallopian tubes or pelvic inflammatory disease 01

Polycystic ovary syndrome or multiple ovary cysts 02

Premature ovarian failure 03

Reduced ovarian production because of your age or medical cause 04

Endometriosis 05

A problem with your uterus, for example uterine fibroids, scar tissue, or abnormal uterine structure 06

Fertility problems because your mother took DES when she was pregnant with you 07

Antisperm antibodies (ASK D20) 08

Another condition that caused fertility problems (SPECIFY) 90

Unexplained infertility 96

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:






IF FATHER UNKNOWN (B12 = 01), SKIP TO D23.








IF D19 NOT EQUAL TO 08, SKIP TO D21.







D20.

Were the anti-sperm antibodies associated with (CHILD)’s father or a different partner?


(CHILD’S) FATHER 01

DIFFERENT PARTNER 02

N/A (SKIP) 97

RF 98

DK 99






D21.

Prior to you becoming pregnant with (CHILD), had (CHILD)’s father ever been told by a doctor or other health care provider that it might be difficult for him to father a child because of a low sperm count or other difficulties with his sperm?


YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99





D22.

Prior to becoming pregnant with (CHILD), had (CHILD)’s father ever been told by a doctor or other health care provider that he had anti-sperm antibodies?


YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99






ASSISTED REPRODUCTION


Now, I’m going to ask you some detailed questions about what type of help you (or [CHILD]’s father) may have received to help you get pregnant. Some of these questions pertain to any time before your pregnancy with (CHILD), others pertain to the time period just prior to your pregnancy with (CHILD) or during your early pregnancy with (CHILD).






IF FATHER UNKNOWN (B12 = 01), SKIP TO D27.







D23.

Prior to becoming pregnant with (CHILD), did (CHILD)’s father take any medications to help you become pregnant with (him/her)?


YES 01

NO (SKIP TO D25) 02

N/A (SKIP) 97

RF (SKIP TO D25) 98

DK (SKIP TO D25) 99






D24.

ASK R TO REFER TO LIST 4a IN PREP GUIDE. What medications did he take? READ BOLDED WORDS AND INDIVIDUAL MEDICATIONS IF NEEDED. CODE ALL THAT APPLY.


Antibiotics 01

Anti-estrogen medications

Clomid 02

Clomiphene citrate 03

Milophene 04

Serophene 05

Tamoxifen 06

Hormonal injections

Bravelle 07

Chorionic Gonadotrophin hCG 08

Fertinex 09

Follistim 10

Follitrophin Alpha 11

Follitrophin Beta 12

FSH 13

Gonal F 14

HCG 15

Humegon 16

Menotrophins: Follicle Stimulating Hormone + Luteinizing Hormone or Interstitial Cell Stimulating Hormone 17

Metrodin 18

Novarel 19

Ovidrel 20

Pergonal 21

Pregnyl 22

Profasi 23

Repronex 24

Urofollitrophin 25

Other male infertility medication

Cabergoline 26

Danazol 27

Donocrine 28

Dostinex 29

Factrel 30

Gonadorelin 31

Leuprolide 32

Lupron 33

Lutrepulse 34

Synarel 35

Nafarelin 36

Medicine to reduce prolactine

Bromocriptine 37

Parlodel 38

Steroid medications 39

Testosterone pill, injections or transdermal gel or patch 40

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY MEDICINE 1:


SPECIFY MEDICINE 2:


SPECIFY MEDICINE 3:





D25.

Prior to becoming pregnant with (CHILD), did (CHILD)’s father ever have any procedures or surgeries to help you become pregnant?


YES 01

NO (SKIP TO D27) 02

N/A (SKIP) 97

RF (SKIP TO D27) 98

DK (SKIP TO D27) 99





D26.

What was the procedure? READ LIST IF NEEDED. Are there any more procedures? CODE ALL THAT APPLY.


Vasectomy reversal 01

Surgery because of varicocele 02

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:


SPECIFY:






D27.

Prior to becoming pregnant with (CHILD), did you ever have any surgical procedures to help you become pregnant such as: to open or rejoin your fallopian tubes, to treat fibroids, or to remove endometriosis?


YES 01

NO (SKIP TO D29) 02

RF (SKIP TO D29) 98

DK (SKIP TO D29) 99





D28.

What was the procedure? Were there any more procedures? CODE ALL THAT APPLY.


OPEN FALLOPIAN TUBES 01

REJOIN FALLOPIAN TUBES 02

TREATMENT OF UTERINE FIBROIDS 03

REMOVAL OF ENDOMETRIOSIS 04

OTHER (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:





d29.

Did you take any medications to help prevent miscarriage with your pregnancy with (CHILD)?


YES 01

NO (SKIP TO D31) 02

RF (SKIP TO D31) 98

DK (SKIP TO D31) 99





D30.

ASK R TO REFER TO LIST 4b IN THE PREP GUIDE. What medications did you take? READ LIST AND CODE ALL THAT APPLY.


Baby aspirin 01

Crinone vaginal gel 02

Gamma Globulin 03

Heparin 04

IVIg Therapy or Immunotherapy 05

Progesterone 06

Progesterone injection or implant 07

Prometrium or other progesterone capsules 08

Steroid treatment (SPECIFY) 09

Vaginal progesterone suppositories 10

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:


SPECIFY:





D31.

Within the two months prior to becoming pregnant with (CHILD),or just after you became pregnant, did you take any medications to help you become pregnant or to maintain the pregnancy in the early stages? Include medications that you took alone as well as medications that you took as part of a broader infertility treatment such as artificial insemination or assisted reproductive technology.


YES 01

NO (SKIP TO D33) 02

RF (SKIP TO D33) 98

DK (SKIP TO D33) 99






D32.

ASK R TO REFER TO LIST 4c IN PREP GUIDE. What medications did you take during those two months? READ BOLDED WORDS AND INDIVIDUAL MEDICATIONS IF NEEDED. CODE ALL THAT APPLY.


Injections or pills to stimulate your ovaries to produce eggs

Bravelle 01

Clomid 02

Clomiphene citrate 03

Fertinex 04

Follistim 05

Follitrophin Alpha 06

Follitrophin Beta 07

FSH 08

Gonal F 09

Humegon 10

Menotrophins: Follicle Stimulating Hormone + Luteinizing Hormone or Interstitial Cell Stimulating Hormone 11

Metrodin 12

Milophene 13

Pergonal 14

Repronex 15

Serophene 16

Urofollitrophin 17

Progesterone medication to prepare the uterine lining for pregnancy or help prevent an early pregnancy loss

Crinone vaginal gel 18

Cyclogest cream 19

Microgest 20

Progesterone implant 21

Progesterone injection 22

Progesterone vaginal suppositories 23

Prometerium 24

Utrogestan 25

Injection to trigger ovulation once your ovaries had produced eggs

Chorionic Gonadotrophin hCG 26

HCG 27

Novarel 28

Ovidrel 29

Pregnyl 30

Profasi 31

Medication to suppress your body’s natural hormone production, injection or nasal spray

Abarelix 32

Antagon 33

Buserelin 34

Cetrotide 35

Deslorelin 36

Eligard 37

Ganirelix 38

Goserelin 39

Historelin 40

Leuprolide 41

Lupron 42

Nafarelin 43

Suprefact 44

Suprecor 45

Synarel 46

Tryptorelin 47

Zoladex 48

Other medications

Bromocriptine 49

Cabaser 50

Cabergoline 51

Danazol 52

Danocrine 53

Dostinex 54

Estradiol patches 55

Estrace pills 56

Factrel 57

Gonadorelin 58

Lutrepulse 59

Parlodel 60

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY MEDICINE 1:


SPECIFY MEDICINE 2:


SPECIFY MEDICINE 3:





D33.

In the month you became pregnant with (CHILD), did you have any procedures such as artificial insemination or assisted reproductive technology to help you become pregnant with (CHILD)?


YES 01

NO (SKIP TO D37) 02

RF (SKIP TO D37) 98

DK (SKIP TO D37) 99


D34A.

A

PROGRAMMER NOTE: ANSWER 01 CANNOT BE COMBINED WITH ANSWERS 02–06.

SK R TO REFER TO LIST 5 IN PREP GUIDE. I’m going to read you a list of procedures. Please tell me if you received any of these to help you get pregnant with (CHILD). READ ANSWERS AND CODE ALL THAT APPLY. (PROBE: Remember, these procedures would have been in the month you became pregnant.)


Artificial insemination or intrauterine insemination 01

Donor embryo transfer 02

Frozen or thawed embryo transfer 03

Gamete intrafallopian transfer or GIFT 04

In vitro fertilization or IVF with vaginal embryo transfer 05

Zygote intrafallopian transfer or ZIFT or pronuclear stage transfer or PROST or tubal embryo transfer or TET 06

Other fertility procedure (SPECIFY) 90

N/A (SKIP) 97

RF (SKIP TO D37) 98

DK (SKIP TO D37) 99


SPECIFY:






IF D34A DOES NOT EQUAL 05, SKIP TO D35.







D

PROGRAMMER NOTE: IF D34A=01, DO NOT ASK DONOR EGGS, DONOR EMBRYOS OR FROZEN EMBRYOS IN D35 AND D36.

34B.

Was intracytoplasmic sperm injection or ICSI used for your in vitro fertilization or IVF with vaginal embryo transfer?


YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99


COMPLETE ONE ROW (D35–D36) FOR EACH ANSWER IN D34A.



D35.

D36.


For (PROCEDURE), were (READ CHOICES) used?

Were (READ CHOICES) used?

PROCEDURE #1:


YES

NO

NA

RF

DK


YES

NO

NA

RF

DK



Donor Eggs

01

02

97

98

99

Frozen sperm

01

02

97

98

99

Donor sperm

01

02

97

98

99

Frozen embryos

01

02

97

98

99

Donor embryos

01

02

97

98

99








PROCEDURE #2:


YES

NO

NA

RF

DK


YES

NO

NA

RF

DK



Donor Eggs

01

02

97

98

99

Frozen sperm

01

02

97

98

99

Donor sperm

01

02

97

98

99

Frozen embryos

01

02

97

98

99

Donor embryos

01

02

97

98

99








PROCEDURE #3:


YES

NO

NA

RF

DK


YES

NO

NA

RF

DK



Donor Eggs

01

02

97

98

99

Frozen sperm

01

02

97

98

99

Donor sperm

01

02

97

98

99

Frozen embryos

01

02

97

98

99

Donor embryos

01

02

97

98

99







# OF ASSISTED REPRODUCTION PROCEDURE SUPPLEMENTS


MORNING SICKNESS



D37.

Now I have some more detailed questions about your pregnancy with (CHILD). Please have the Pregnancy Reference Form handy.


During the pregnancy with (CHILD), did you have any nausea?


YES 01

NO (SKIP TO D40) 02

RF (SKIP TO D40) 98

DK (SKIP TO D40) 99





D38A.

D38B.

D38C.

D38D.

During which months did you have nausea?

Would you say the nausea occurred in the first trimester, from (1) to (3)?

Would you say the nausea occurred in the second trimester, from (4) to (6)?

Would you say the nausea occurred in the third trimester, from (7) to (10)?

VERBATIM:



YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

IF DK, ASK B-D.









COMPLETE ONE ROW FOR EACH
MONTH/TRIMESTER INDICATED.







d39.

How often during (MONTH/TRIMESTER) did you have nausea? Would you say it was (READ ANSWERS)?





MONTH/TRIMESTER

Less than once a week

Once a week

A few times a week

Every day

N/A (SKIP)

RF

DK


1.

01

02

03

04

97

98

99


2.

01

02

03

04

97

98

99


3.

01

02

03

04

97

98

99


4.

01

02

03

04

97

98

99


5.

01

02

03

04

97

98

99


6.

01

02

03

04

97

98

99


7.

01

02

03

04

97

98

99


8.

01

02

03

04

97

98

99


9.

01

02

03

04

97

98

99


10.

01

02

03

04

97

98

99



D40.

During the pregnancy with (CHILD), did you have any vomiting?


YES 01

NO (SKIP TO D43) 02

RF (SKIP TO D43) 98

DK (SKIP TO D43) 99





D41A.

D41B.

D41C.

D41D.

During which months did you have vomiting?

Would you say the vomiting occurred in the first trimester, from (1) to (3)?

Would you say the vomiting occurred in the second trimester, from (4) to (6)?

Would you say the vomiting occurred in the third trimester, from (7) to (10)?

VERBATIM:



YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

IF DK, ASK B-D.









COMPLETE ONE ROW FOR EACH
MONTH/TRIMESTER INDICATED.







d42.

How often during (MONTH/TRIMESTER) did you have vomiting? Would you say it was (READ ANSWERS)?





MONTH/TRIMESTER

Less than once a week

Once a week

A few times a week

Every day

N/A (SKIP)

RF

DK


1.

01

02

03

04

97

98

99


2.

01

02

03

04

97

98

99


3.

01

02

03

04

97

98

99


4.

01

02

03

04

97

98

99


5.

01

02

03

04

97

98

99


6.

01

02

03

04

97

98

99


7.

01

02

03

04

97

98

99


8.

01

02

03

04

97

98

99


9.

01

02

03

04

97

98

99


10.

01

02

03

04

97

98

99



IF NO NAUSEA OR VOMITING (BOTH D37 AND D40 = 02, 98, OR 99), SKIP TO D45.







d43.

Did you ever require medical treatment for the nausea or vomiting?


YES 01

NO (SKIP TO D45) 02

N/A (SKIP) 97

RF (SKIP TO D45) 98

DK (SKIP TO D45) 99





D44a.

What medicine did you take? Was it (READ ANSWERS AND CODE ALL THAT APPLY)?


Vitamin B6 or pyridoxine 01

Unisom or doxylamine 02

Emetrol 03

Ginger 04

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:


SPECIFY:





D44b.

Did you require any other medical treatments for the nausea such as Sea Bands or bed rest?


YES ……………………..(SPECIFY) 01

NO 02

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:






PRENATAL CARE



D45.

Between (-3) and (DOIB/END BF), did you take any prenatal vitamins? A prenatal vitamin is a special vitamin supplement sometimes taken by pregnant women or women trying to get pregnant.


YES 01

NO 02

RF 98

DK 99





D46.

Between (-3) and (DOIB/END BF), did you take any other vitamins or minerals?


YES 01

NO (SKIP TO D48) 02

RF (SKIP TO D48) 98

DK (SKIP TO D48) 99





D47.

Did you take (READ ANSWERS AND CODE ALL THAT APPLY)?


Multivitamins 01

Vitamin A 02

Folic Acid 03

Iron 04

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:


SPECIFY:





D48.

During your pregnancy with (CHILD), how many ultrasounds did you have?


NONE (SKIP TO D52) 00

# OF ULTRASOUNDS

RF (SKIP TO D52) 98

DK 99






D49.

Did you have any ultrasounds which showed any problems or confirmed abnormalities with the fetus, placenta, amniotic fluid, or any other problems?


YES 01

NO (SKIP TO D52) 02

N/A (SKIP) 97

RF (SKIP TO D52) 98

DK (SKIP TO D52) 99





D50.

Was the problem or abnormality with (READ ANSWERS AND CODE ALL THAT APPLY)?


Fetal growth (SPECIFY) 01

Placenta (SPECIFY) 02

Biophysical profile or BPP (SPECIFY) 03

Decreased fetal movement (SPECIFY) 04

Amniotic fluid volume (SPECIFY) 05

A fetal malformation or defect (SPECIFY) 06

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:


SPECIFY:


SPECIFY:





D51A.

D51B.

D51C.

D51D.

What month of pregnancy were you in when you had your first ultrasound that showed an abnormality?

Would you say the first ultrasound that showed an abnormality occurred in the first trimester, from (1) to (3)?

Would you say the first ultrasound that showed an abnormality occurred in the second trimester, from (4) to (6)?

Would you say the first ultrasound that showed an abnormality occurred in the third trimester, from (7) to (10)?

VERBATIM:



YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

IF DK, ASK B-D.






BLOOD TESTS



D52.

D53.

D54.

I am now going to ask about blood tests. When you were pregnant with (CHILD), did you have (READ LIST)?

Were the results of the test normal or abnormal?

Were the results high or low?


YES

NO

RF

DK

N

AB

NA

RF

DK

H

L

NA

RF

DK


(ASK D53)














MSAFP or maternal serum alpha fetoprotein

01

02

98

99

01

02

97

98

99

01

02

97

98

99







(ASK D54)









Double screen

01

02

98

99

01

02

97

98

99






Triple screen

01

02

98

99

01

02

97

98

99






Quad screen

01

02

98

99

01

02

97

98

99







D55.

D56.

D57.

Did you have an Amniocentesis or amnio?

Were the results of the test normal or abnormal?

What was the abnormality? SPECIFY.


YES

NO

RF

DK

N

AB

NA

RF

DK


(ASK D56)





(ASK D57)




Amnio



01



02



98



99



01



02



97



98



99

N/A (SKIP) 97

RF 98

DK 99


D58.

D59.

D60.

Did you have a Chorionic Villus Sampling or CVS?

Did the test show any abnormalities?

What was the abnormality? SPECIFY.


YES

NO

RF

DK

YES

NO

NA

RF

DK


(ASK D59)




(ASK D60)





CVS



01



02



98



99



01



02



97



98



99

N/A (SKIP) 97

RF 98

DK 99



D61.

Did you have any other prenatal diagnostic test? What was the test? (PROBE: Fetal echocardiography or fetal dye studies?) Any other tests?


YES (SPECIFY IN GRID) 01

NO (SKIP TO D64) 02

RF (SKIP TO D64) 98

DK (SKIP TO D64) 99






D62A.

D62B.

D62C.

COMPLETE ONE ROW (D62–D63) FOR EACH TEST NAMED.

Between (DOC) and (DOIB), when was (TEST) done?

Would you say you had (TEST) done in your first trimester, from (1) to (3)?

Would you say you had (TEST) done in your second trimester, from (4) to (6)?

TEST:







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#1:

D62A VERBATIM:



1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-D. OTHERWISE, SKIP TO D63.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#2:

D62A VERBATIM:







1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-D. OTHERWISE, SKIP TO D63.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#3:

D62A VERBATIM:







1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-D. OTHERWISE, SKIP TO D63.





D62.

Did you have any other prenatal diagnostic test? PROBE: Fetal echocardiography or fetal dye studies? PROBE: Any other tests?


YES (SPECIFY IN GRID) 01

NO (SKIP TO D65) 02

RF (SKI PTO D65) 98

DK (SKIP TO D65) 99





D62D.

D63.


Would you say you had (TEST) done in your third trimester, from (7) to (10)?

Why was (TEST) done? SPECIFY.





N/A (SKIP) 97

RF 98

DK 99


YES

NO

N/A

RF

DK


01

02

97

98

99






YES

NO

N/A

RF

DK




N/A (SKIP) 97

RF 98

DK 99


01

02

97

98

99






YES

NO

N/A

RF

DK




N/A (SKIP) 97

RF 98

DK 99


01

02

97

98

99






# OF PRENATAL TEST SUPPLEMENTS


D64.

Did you or (CHILD) have any other prenatal medical procedures such as blood transfusions or fetal surgery? What was the procedure? Did you have any other procedures?


YES (SPECIFY IN GRID) 01

NO (SKIP TO D67) 02

RF (SKI PTO D67) 98

DK (SKIP TO D67) 99






D65A.

D65B.

D65C.

COMPLETE ONE ROW (D65–D66) FOR EACH PROCEDURE NAMED.

Between (DOC) and (DOIB), when was (PROCEDURE) done?

Would you say you had (PROCEDURE) done in your first trimester, from (1) to (3)?

Would you say you had (PROCEDURE) done in your second trimester, from (4) to (6)?

PROCEDURE:







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#1:

D65A VERBATIM:



1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-D. OTHERWISE, SKIP TO D66.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#2:

D65A VERBATIM:







1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-D. OTHERWISE, SKIP TO D66.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#3:

D65A VERBATIM:







1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-D. OTHERWISE, SKIP TO D66.





D62.

Did you have any other prenatal diagnostic test? PROBE: Fetal echocardiography or fetal dye studies? PROBE: Any other tests?


YES (SPECIFY IN GRID) 01

NO (SKIP TO D65) 02

RF (SKI PTO D65) 98

DK (SKIP TO D65) 99





D65D.

D66.


Would you say you had (PROCEDURE) done in your third trimester, from (7) to (10)?

Why was (PROCEDURE) done? SPECIFY.





N/A (SKIP) 97

RF 98

DK 99


YES

NO

N/A

RF

DK


01

02

97

98

99







YES

NO

N/A

RF

DK




N/A (SKIP) 97

RF 98

DK 99


01

02

97

98

99







YES

NO

N/A

RF

DK




N/A (SKIP) 97

RF 98

DK 99


01

02

97

98

99






# OF PRENATAL MEDICAL PROCEDURE SUPPLEMENTS


D67.

Were you told that there was “Rhesus” or “Rh” incompatibility between you and (CHILD)?


YES 01

NO (SKIP TO D70) 02

RF (SKIP TO D70) 98

DK (SKIP TO D70) 99





D68.

If your blood type was RH negative when you were pregnant with (CHILD), you might have been given injections of Rhogam. Did you receive any Rhogam injections while you were pregnant or soon after you gave birth?


YES, WHILE PREGNANT 01

YES, SOON AFTER GIVING BIRTH 02

YES, BOTH TIMES 03

NO 04

N/A (SKIP) 97

RF 98

DK 99





D69A.

Were there any problems with (CHILD) because of the rhesus incompatibility?


YES 01

NO (SKIP TO D70) 02

N/A (SKIP) 97

RF (SKIP TO D70) 98

DK (SKIP TO D70) 99





D69B.

What were the problems? SPECIFY.


PROBLEMS:


N/A (SKIP) 97

RF 98

DK 99






IF ONLY ONE PREGNANCY (C3 = 1), SKIP TO D71.







D70.

Did you receive Rhogam injections for any pregnancy other than your pregnancy with (CHILD)?


YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99






VAGINAL DOUCHING



D71.

Did you ever douche between (-3) and (DOIB/END BF)?


YES 01

NO (SKIP TO E1) 02

RF (SKIP TO E1) 98

DK (SKIP TO E1) 99








D72A.

D72B.

D72C.


Between (-3) and (DOIB/END BF), which months did you douche?

Did you douche in the three months before you became pregnant, from (-3) to (-1)?

Did you douche in your first trimester, from (1) to (3)?







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

D72A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.





IF R DID NOT BREASTFEED, SKIP TO D73.






D72D.

D72E.

D72F.


Did you douche in your second trimester, from (4) to (6)?

Did you douche in your third trimester, from (7) to (10)?

Did you douche during the months you breastfed, from (DOIB/10) to (END BF)?



YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99







COMPLETE ONE ROW FOR EACH MONTH/TRIMESTER INDICATED.






d73.

How often during (MONTH/TRIMESTER) did you douche? Would you say it was (READ ANSWERS)?


MONTH/TRIMESTER

More than once a week

Once a week

Once every 2-3 weeks

Once a month or less

N/A (SKIP)

RF

DK


1.

01

02

03

04

97

98

99


2.

01

02

03

04

97

98

99


3.

01

02

03

04

97

98

99


4.

01

02

03

04

97

98

99


5.

01

02

03

04

97

98

99


6.

01

02

03

04

97

98

99


7.

01

02

03

04

97

98

99


8.

01

02

03

04

97

98

99


9.

01

02

03

04

97

98

99


10.

01

02

03

04

97

98

99


11.

01

02

03

04

97

98

99


12.

01

02

03

04

97

98

99


13.

01

02

03

04

97

98

99


14.

01

02

03

04

97

98

99
















BLANK PAGE FOR END OF SECTION







SECTION E: MATERNAL MEDICAL CONDITIONS, SURGERIES, PROCEDURES, AND MEDICATION USE

Now, I am going to ask you about some illnesses, surgeries and other procedures that you might have had during your pregnancy with (CHILD). I’m going to ask you about the time period from three months before you became pregnant with (CHILD) until ([his/her] delivery/you stopped breastfeeding completely).





REPRODUCTIVE AND MAJOR PERINATAL INFECTIONS AND CONDITIONS

I am going to start off by asking you about some infections or conditions that you might have had during the time period from three months before you became pregnant with (CHILD) until ([his/her] delivery/you stopped breastfeeding completely). Please refer to list 6 in your preparatory guide and follow along.





E1.

Between (-3) and (DOIB/END BF) did you have any of the following illnesses? READ LIST AND CODE ALL THAT APPLY.





Bacterial Vaginosis 01

Candidiasis or Yeast Infection 02

Chicken Pox 03

Chlamydia 04

Cystitis NOS 05

Cytomegalovirus 06

Encephalitis 07

Endocarditis 08

Endometriosis 09

Fibroids 10

Genital Herpes 11

Group B Streptococcal infection 12

Hepatitis (PROBE):

HEPATITIS A 13

HEPATITIS B 14

HEPATITIS C 15

HEPATITIS NOS 16

HIV/AIDS 17

Human Papilloma Virus or HPV or Genital warts or venereal warts 18

Influenza or flu 19

Meningitis 20

Mononucleosis or mono 21

Myocarditis 22

Parvovirus or Fifth disease 23

Pelvic Inflammatory Disease or PID 24

Pneumonia 25

Pyelonephritis or kidney infection 26

Rubella or German measles 27

Septicemia or blood infection 28

Shingles 29

Staphylococcal infection or cysts 30

Syphilis 31

Toxoplasmosis 32

Trichomoniasis or trich 33

Upper respiratory infection 34

Urinary tract infection 35

Vaginitis NOS 36

Other conditions
(SPECIFY) 90

RF 98

DK 99

NO CONDITIONS 00






SPECIFY:


SPECIFY:


SPECIFY:






IF E1 = 00, 98 OR 99, SKIP TO E11.




COMPLETE E2–E7 FOR EACH CONDITION IN E1.



IF E1 = 07 (HERPES) OR 13 (VENEREAL WARTS), ASK E2 ABOUT OUTBREAKS.



E2A.

E2B.

E2C.

CONDITION 1:

During which months from
(-3) to (DOIB/END BF) did you have (CONDITION)?

Would you say (CONDITION) occurred in the 3 months before you became pregnant, from (-3) to (-1)?

Would you say (CONDITION) occurred in your first trimester, from (1) to (3)?


E2A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















E3.

D id you take any medicine for (CONDITION) between (-3) and (DOIB/END BF)? (IF YES: ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine did you take? The medications in the list have been organized as best as possible by condition so please look for the heading and find your medication under that. If you do not see your medication, please look under the “other medications” category. If your medication is not listed at all, we still want you to tell us about it. Medications can be in pill form, nasal spray, patches, creams, injections, shots, etc. Any others?)


E4A.

E4B.

E 4C.

MEDICINE:

During which months from
(-3) to (DOIB/END BF) did you take (MEDICINE) for (CONDITION)?

Would you say you took (MED) in the three months before you became pregnant, from (-3) to (-1)?

Would you say you took (MEDICINE) in your first trimester, from (1) to (3)?

#1:

E4A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















#2:

E4A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















E5.

Did you have a fever from (CONDITION) between
(-3) and (DOIB/END BF)?


YES 01

NO (SKIP TO NEXT CONDITION/E8) 02

N/A (SKIP) 97

RF (SKIP TO NEXT CONDITION/E8) 98

DK (SKIP TO NEXT CONDITION/E8) 99






E6A.

E6B.

E6C.


During which months from
(-3) to (DOIB/END BF) did you have a fever?

Would you say the fever occurred in the 3 months before you became pregnant, from (-3) to (-1)?

Would you say the fever occurred in your first trimester, from (1) to (3)?

E6A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F. OTHERWISE, SKIP TO E7.












E

IF R DID NOT BREASTFEED, SKIP TO E3.

2D.

E2E.

E2F.


Would you say (CONDITION) occurred in your second trimester, from (4) to (6)?

Would you say (CONDITION) occurred in your third trimester, from (7) to (10)?

Would you say (CONDITION) occurred during the months you breastfed, from (DOIB/10) to (END BF)?


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99



IF DK, ASK B-F.















YES (SPECIFY IN GRID) 01

NO (SKIP TO E5) 02

N/A (SKIP) 97

RF (SKIP TO E5) 98

DK (SKIP TO E5) 99



E4D.

E4E.

E4F.


Would you say you took (MEDICINE) in your second trimester, from (4) to (6)?

Would you say you took (MEDICINE) in your third trimester, from (7) to (10)?

Would you say you took (MEDICINE) during the months you breastfed, from (DOIB/10) to (END BF)?


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


# OF PERINATAL CONDITION 1 MEDICINE SUPPLEMENTS




IF R DID NOT BREASTFEED,
SKIP TO E7.




E6D.

E6E.

E6F.

E7.

Would you say the fever occurred in your second trimester, from (4) to (6)?

Would you say the fever occurred in your third trimester, from (7) to (10)?

Would you say the fever occurred during the months you breastfed, from (DOIB/10) to (END BF)?

W

C

F

hat was the highest temperature recorded using a thermometer during your fever?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

TEMP . C

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

NA (SKIP) 997

RF 998

DK 999



E2A.

E2B.

E2C.

CONDITION 2:

During which months from
(-3) to (DOIB/END BF) did you have (CONDITION)?

Would you say (CONDITION) occurred in the 3 months before you became pregnant, from (-3) to (-1)?

Would you say (CONDITION) occurred in your first trimester, from (1) to (3)?


E2A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















E3.

D id you take any medicine for (CONDITION) between (-3) and (DOIB/END BF)? (IF YES: ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine did you take? The medications in the list have been organized as best as possible by condition so please look for the heading and find your medication under that. If you do not see your medication, please look under the “other medications” category. If your medication is not listed at all, we still want you to tell us about it. Medications can be in pill form, nasal spray, patches, creams, injections, shots, etc. Any others?)


E4A.

E4B.

E 4C.

MEDICINE:

During which months from
(-3) to (DOIB/END BF) did you take (MEDICINE) for (CONDITION)?

Would you say you took (MED) in the three months before you became pregnant, from (-3) to (-1)?

Would you say you took (MEDICINE) in your first trimester, from (1) to (3)?

#1:

E4A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















#2:

E4A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















E5.

Did you have a fever from (CONDITION) between
(-3) and (DOIB/END BF)?


YES 01

NO (SKIP TO NEXT CONDITION/E8) 02

N/A (SKIP) 97

RF (SKIP TO NEXT CONDITION/E8) 98

DK (SKIP TO NEXT CONDITION/E8) 99






E6A.

E6B.

E6C.


During which months from
(-3) to (DOIB/END BF) did you have a fever?

Would you say the fever occurred in the 3 months before you became pregnant, from (-3) to (-1)?

Would you say the fever occurred in your first trimester, from (1) to (3)?

E6A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F. OTHERWISE, SKIP TO E7.











E

IF R DID NOT BREASTFEED, SKIP TO E3.

2D.

E2E.

E2F.


Would you say (CONDITION) occurred in your second trimester, from (4) to (6)?

Would you say (CONDITION) occurred in your third trimester, from (7) to (10)?

Would you say (CONDITION) occurred during the months you breastfed, from (DOIB/10) to (END BF)?


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99



IF DK, ASK B-F.















YES (SPECIFY IN GRID) 01

NO (SKIP TO E5) 02

N/A (SKIP) 97

RF (SKIP TO E5) 98

DK (SKIP TO E5) 99



E4D.

E4E.

E4F.


Would you say you took (MEDICINE) in your second trimester, from (4) to (6)?

Would you say you took (MEDICINE) in your third trimester, from (7) to (10)?

Would you say you took (MEDICINE) during the months you breastfed, from (DOIB/10) to (END BF)?


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


# OF PERINATAL CONDITION 2 MEDICINE SUPPLEMENTS




IF R DID NOT BREASTFEED,
SKIP TO E7.




E6D.

E6E.

E6F.

E7.

Would you say the fever occurred in your second trimester, from (4) to (6)?

Would you say the fever occurred in your third trimester, from (7) to (10)?

Would you say the fever occurred during the months you breastfed, from (DOIB/10) to (END BF)?

W

C

F

hat was the highest temperature recorded using a thermometer during your fever?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

TEMP . C

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

NA (SKIP) 997

RF 998

DK 999



E2A.

E2B.

E2C.

CONDITION 3:

During which months from
(-3) to (DOIB/END BF) did you have (CONDITION)?

Would you say (CONDITION) occurred in the 3 months before you became pregnant, from (-3) to (-1)?

Would you say (CONDITION) occurred in your first trimester, from (1) to (3)?


E2A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















E3.

D id you take any medicine for (CONDITION) between (-3) and (DOIB/END BF)? (IF YES: ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine did you take? The medications in the list have been organized as best as possible by condition so please look for the heading and find your medication under that. If you do not see your medication, please look under the “other medications” category. If your medication is not listed at all, we still want you to tell us about it. Medications can be in pill form, nasal spray, patches, creams, injections, shots, etc. Any others?)


E4A.

E4B.

E 4C.

MEDICINE:

During which months from
(-3) to (DOIB/END BF) did you take (MEDICINE) for (CONDITION)?

Would you say you took (MED) in the three months before you became pregnant, from (-3) to (-1)?

Would you say you took (MEDICINE) in your first trimester, from (1) to (3)?

#1:

E4A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















#2:

E4A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















E5.

Did you have a fever from (CONDITION) between
(-3) and (DOIB/END BF)?


YES 01

NO (SKIP TO NEXT CONDITION/E8) 02

N/A (SKIP) 97

RF (SKIP TO NEXT CONDITION/E8) 98

DK (SKIP TO NEXT CONDITION/E8) 99






E6A.

E6B.

E6C.


During which months from
(-3) to (DOIB/END BF) did you have a fever?

Would you say the fever occurred in the 3 months before you became pregnant, from (-3) to (-1)?

Would you say the fever occurred in your first trimester, from (1) to (3)?

E6A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F. OTHERWISE, SKIP TO E7.











E

IF R DID NOT BREASTFEED, SKIP TO E3.

2D.

E2E.

E2F.


Would you say (CONDITION) occurred in your second trimester, from (4) to (6)?

Would you say (CONDITION) occurred in your third trimester, from (7) to (10)?

Would you say (CONDITION) occurred during the months you breastfed, from (DOIB/10) to (END BF)?


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99



IF DK, ASK B-F.















YES (SPECIFY IN GRID) 01

NO (SKIP TO E5) 02

N/A (SKIP) 97

RF (SKIP TO E5) 98

DK (SKIP TO E5) 99



E4D.

E4E.

E4F.


Would you say you took (MEDICINE) in your second trimester, from (4) to (6)?

Would you say you took (MEDICINE) in your third trimester, from (7) to (10)?

Would you say you took (MEDICINE) during the months you breastfed, from (DOIB/10) to (END BF)?


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


# OF PERINATAL CONDITION 3 MEDICINE SUPPLEMENTS




IF R DID NOT BREASTFEED,
SKIP TO E7.




E6D.

E6E.

E6F.

E7.

Would you say the fever occurred in your second trimester, from (4) to (6)?

Would you say the fever occurred in your third trimester, from (7) to (10)?

Would you say the fever occurred during the months you breastfed, from (DOIB/10) to (END BF)?

W

C

F

hat was the highest temperature recorded using a thermometer during your fever?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

TEMP . C

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

NA (SKIP) 997

RF 998

DK 999

# OF PERINATAL CONDITION SUPPLEMENTS




ORAL/DENTAL DISEASE







E8.

Between (-3) and (DOIB/END BF) did a doctor or dentist ever tell you that you had gingivitis or periodontitis?


YES 01

NO (SKIP TO E15) 02

RF (SKIP TO E15) 98

DK (SKIP TO E15) 99





E9.

Did you take any medication for gingivitis or periodontitis between (-3) and (DOIB/END BF)?


YES 01

NO (SKIP TO E12) 02

N/A (SKIP) 97

RF (SKIP TO E12) 98

DK (SKIP TO E12) 99





E10.

ASK R TO REFER TO LIST 7a IN PREP GUIDE. What medicine did you take? Anything else? IF R CAN’T RECALL, READ ANSWERS AND CODE ALL THAT APPLY.


Clindamycin 01

Doxycycline 02

Metronidazole 03

Minocycline 04

Penicillin 05

Other (SPECIFY IN GRID) 90

N/A (SKIP) 97

RF 98

DK 99



E11A.

E11B.

E11C.

COMPLETE ONE ROW FOR EACH MEDICINE.

During which months from
(-3) to (DOIB/END BF) did you take (MED)?

Would you say you took (MED) in the 3 months before you became pregnant, from (-3) to (-1)?

Would you say you took (MED) in your first trimester, from (1) to (3)?








YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#1:

E11A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#2:

E11A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#3:

E11A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.




ORAL/DENTAL DISEASE







E11.

Between (-3) and (DOIB/END BF) did a doctor or dentist ever tell you that you had gingivitis or periodontitis?


YES 01

NO (SKIP TO E18) 02

RF (SKIP TO E18) 98

DK (SKIP TO E18) 99





E12.

Did you take any medication for gingivitis or periodontitis between (-3) and (DOIB/END BF)?


YES 01

NO (SKIP TO E15) 02

N/A (SKIP) 97

RF (SKIP TO E15) 98

DK (SKIP TO E15) 99





E13.

W

IF R DID NOT BREASTFEED,
SKIP TO NEXT MED/E12.

hat medicine did you take? PROBE: Anything else? IF R CAN’T RECALL, READ LIST AND CODE ALL THAT APPLY. IF THESE MEDICATIONS WERE NOT GIVEN, ASK R TO REFER TO LIST 8a IN PREP GUIDE UNDER ANTIBIOTICS AND RECORD MEDICATION BELOW.


Penicillin 01

Clindamycin 02

Metronidazole 03

Minocycline 04

Doxycycline 05

Other (SPECIFY IN GRID) 90

N/A (SKIP) 97

RF 98

DK 99


E11D.

E11E.

E11F.


Would you say you took (MED) in your second trimester, from (4) to (6)?

Would you say you took (MED) in your third trimester, from (7) to (10)?

Would you say you took (MED) during the months you breastfed, from (DOIB/10) to (END BF)?


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99






YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


# OF DENTAL MEDICINE SUPPLEMENTS


E12.

Did you have any treatment other than medicine or antibiotics for gingivitis or periodontitis between (-3) and (DOIB/END BF)?


YES 01

NO (SKIP TO E15) 02

N/A (SKIP) 97

RF (SKIP TO E15) 98

DK (SKIP TO E15) 99





E13.

What treatments did you have? Was it (READ ANSWERS AND CODE ALL THAT APPLY)?


Root planing and scaling 01

Gingival curettage 02

Splinting 03

Other (SPECIFY IN GRID) 90

N/A (SKIP) 97

RF 98

DK 99



E14A.

E14B.

E14C.

COMPLETE ONE ROW FOR EACH TREATMENT.

During which months from
(-3) to (DOIB/END BF) did you get (TREATMENT)?

Would you say you got (TREATMENT) in the 3 months before you became pregnant, from (-3) to (-1)?

Would you say you got (TREATMENT) in your first trimester, from (1) to (3)?








YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#1:

E14A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#2:

E14A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#3:

E14A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.




ORAL/DENTAL DISEASE





E15.

Did you have any treatment other than medicine or antibiotics for gingivitis or periodontitis between (-3) and (DOIB/END BF)?


YES 01

NO (SKIP TO E18) 02

N/A (SKIP) 97

RF (SKIP TO E18) 98

DK (SKIP TO E18) 99





E16.

W

IF R DID NOT BREASTFEED,
SKIP TO NEXT TREATMENT/E15.

hat treatments did you have? Was it (READ ANSWERS AND CODE ALL THAT APPLY)?


Root planning and scaling 01

Gingival curettage 02

Splinting 03

Other (SPECIFY IN GRID) 90

N/A (SKIP) 97

RF 98

DK 99


E14D.

E14E.

E14F.


Would you say you got (TREATMENT) in your second trimester, from (4) to (6)?

Would you say you got (TREATMENT) in your third trimester, from (7) to (10)?

Would you say you got (TREATMENT) during the months you breastfed, from (DOIB/10) to (END BF)?


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99



# OF DENTAL TREATMENT SUPPLEMENTS




INJURIES




The next few questions are about any injuries that you might have had during the time period from three months prior to conception of (CHILD) through (DOIB/the time until you completely stopped breastfeeding).





E15.

Between (-3) and (DOIB/END BF) did you have any injuries that required medical attention?


YES 01

NO (SKIP TO E21) 02

RF (SKIP TO E21) 98

DK (SKIP TO E21) 99





E16.

What were the injuries you had? SPECIFY.


INJURY 1:


INJURY 2:


INJURY 3:





N/A (SKIP) 97

RF 98

DK 99



COMPLETE E17-E20 FOR EACH INJURY.




E17A.

E17B.

E17C.

INJURY 1:

Between (-3) and (DOIB/ END BF) during which month did (INJURY) happen?

Would you say (INJURY) occurred in the three months before you became pregnant, from (-3) to (-1)?

Would you say (INJURY) occurred in your first trimester, from (1) to (3)?


E17A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F. OTHERWISE, SKIP TO E18.

IF R DID NOT BREASTFEED,
SKIP TO E18.












E17D.

E17E

E17F.

E18.

Would you say (INJURY) occurred in your second trimester, from (4) to (6)?

Would you say (INJURY) occurred in your third trimester, from (7) to (10)?

Would you say (INJURY) occurred during the months you breastfed, from (DOIB/10) to (END BF)?

Did you ever lose consciousness because of (INJURY)?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99





E19.

Did you take any medications or receive injections because of (INJURY)?


YES 01

NO (SKIP TO NEXT INJURY/E21) 02

N/A (SKIP) 97

RF (SKIP TO NEXT INJURY/E21) 98

DK (SKIP TO NEXT INJURY/E21) 99





E20.

ASK R TO LOOK AT LIST 7a THROUGH 7p PAYING CLOSE ATTENTION TO 7a AND 7b IN PREP GUIDE. What medicines or injections did you take for (INJURY)? Anything else?


MEDICINE 1:


MEDICINE 2:


MEDICINE 3:





N/A (SKIP) 97

RF 98

DK 99




E17A.

E17B.

E17C.

INJURY 2:

Between (-3) and (DOIB/ END BF) during which month did (INJURY) happen?

Would you say (INJURY) occurred in the three months before you became pregnant, from (-3) to (-1)?

Would you say (INJURY) occurred in your first trimester, from (1) to (3)?


E17A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F. OTHERWISE, SKIP TO E18.

IF R DID NOT BREASTFEED,
SKIP TO E18.












E17D.

E17E

E17F.

E18.

Would you say (INJURY) occurred in your second trimester, from (4) to (6)?

Would you say (INJURY) occurred in your third trimester, from (7) to (10)?

Would you say (INJURY) occurred during the months you breastfed, from (DOIB/10) to (END BF)?

Did you ever lose consciousness because of (INJURY)?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99





E19.

Did you take any medications or receive injections because of (INJURY)?


YES 01

NO (SKIP TO NEXT INJURY/E21) 02

N/A (SKIP) 97

RF (SKIP TO NEXT INJURY/E21) 98

DK (SKIP TO NEXT INJURY/E21) 99





E20.

ASK R TO LOOK AT LIST 7a THROUGH 7p PAYING CLOSE ATTENTION TO 7a AND 7b IN PREP GUIDE. What medicines or injections did you take for (INJURY)? Anything else?


MEDICINE 1:


MEDICINE 2:


MEDICINE 3:





N/A (SKIP) 97

RF 98

DK 99




E17A.

E17B.

E17C.

INJURY 3:

Between (-3) and (DOIB/ END BF) during which month did (INJURY) happen?

Would you say (INJURY) occurred in the three months before you became pregnant, from (-3) to (-1)?

Would you say (INJURY) occurred in your first trimester, from (1) to (3)?


E17A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F. OTHERWISE, SKIP TO E18.

IF R DID NOT BREASTFEED,
SKIP TO E18.












E17D.

E17E.

E17F.

E18.

Would you say (INJURY) occurred in your second trimester, from (4) to (6)?

Would you say (INJURY) occurred in your third trimester, from (7) to (10)?

Would you say (INJURY) occurred during the months you breastfed, from (DOIB/10) to (END BF)?

Did you ever lose consciousness because of (INJURY)?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99





E19.

Did you take any medications or receive injections because of (INJURY)?


YES 01

NO (SKIP TO NEXT INJURY/E21) 02

N/A (SKIP) 97

RF (SKIP TO NEXT INJURY/E21) 98

DK (SKIP TO NEXT INJURY/E21) 99





E20.

ASK R TO LOOK AT LIST 7a THROUGH 7p PAYING CLOSE ATTENTION TO 7a AND 7b IN PREP GUIDE. What medicines or injections did you take for (INJURY)? Anything else?


MEDICINE 1:


MEDICINE 2:


MEDICINE 3:





N/A (SKIP) 97

RF 98

DK 99


# OF PERINATAL INJURY SUPPLEMENTS



SURGERY





Now I’m going to ask you about any surgeries or procedures not related to pregnancy or delivery that you might have had during the time period from three months before becoming pregnant with (CHILD) through the time until (DOIB/you completely stopped breastfeeding).







E21.

Between (-3) and (DOIB/END BF) did you have any dental, medical, or surgical procedures that required the use of general or local anesthesia? (PROBE: What procedures did you have done?)


YES (SPECIFY IN GRID) 01

NO (SKIP TO E24) 02

RF (SKIP TO E24) 98

DK (SKIP TO E24) 99








COMPLETE E22–E23 FOR EACH PROCEDURE.





E22.

E23A.

E23B.

PROCEDURE:

For (PROCEDURE) did you have general anesthesia or local anesthesia?

In which month between (-3) and (DOIB/END BF) did you receive the anesthesia?

VERBATIM:


Would you say you received the anesthesia in the three months before you became pregnant, from (-3) to (-1)?

#1:

GENERAL 01

LOCAL 02

N/A (SKIP) 97

RF 98

DK 99

-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

01

02

97

98

99



IF E22 = 98, SKIP TO NEXT PROCEDURE/E24.

IF DK, ASK B-F.









VERBATIM:







#2:

GENERAL 01

LOCAL 02

N/A (SKIP) 97

RF 98

DK 99

-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

01

02

97

98

99



IF E22 = 98, SKIP TO NEXT PROCEDURE/E24.

IF DK, ASK B-F.









VERBATIM:







#3:

GENERAL 01

LOCAL 02

N/A (SKIP) 97

RF 98

DK 99

-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

01

02

97

98

99



IF E22 = 98, SKIP TO NEXT PROCEDURE/E24.

IF DK, ASK B-F.










SURGERY




Now I’m going to ask you about any surgeries or procedures not related to pregnancy or delivery that you might have had during the time period from three months before becoming pregnant with (CHILD) through the time until (DOIB/you completely stopped breastfeeding).





E24.

Between (-3) and (DOIB/END BF) did you have any dental, medical, or surgical procedures that required the use of general or local anesthesia?


YES 01

NO (SKIP TO E28) 02

RF (SKIP TO E28) 98

DK (SKIP TO E28) 99




IF R DID NOT BREASTFEED,
SKIP TO NEXT PROC/E24.




E23C.

E23D.

E23E.

E23F.

Would you say you received the anesthesia in your first trimester, from (1) to (3)?

Would you say you received the anesthesia in your second trimester, from (4) to (6)?

Would you say you received the anesthesia in your third trimester, from (7) to (10)?

VERBATIM:


Would you say you received the anesthesia during the months you breastfed, from (DOIB/10) to (END BF)?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99






IF E26 = 98, SKIP TO NEXT PROCEDURE/E28.

IF DK, ASK B-F.









VERBATIM:







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99






IF E26 = 98, SKIP TO NEXT PROCEDURE/E28.

IF DK, ASK B-F.









VERBATIM:







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99






IF E26 = 98, SKIP TO NEXT PROCEDURE/E28.

IF DK, ASK B-F.






# OF NON-PREGNANCY PROCEDURE SUPPLEMENTS



OTHER PROCEDURES







E24.

Between (-3) and (DOIB/END BF) did you have any of the following procedures not related to your pregnancy with (CHILD)? READ ANSWERS AND CODE ALL THAT APPLY.


X-rays, including dental 01

Mammogram 02

CT/CAT scans 03

MRI or magnetic resonance imaging 04

Radionuclide study or scan 05

Radiation treatments 06

Other x-rays or scans 07

Other (SPECIFY IN GRID) 90

NONE (SKIP TO E27) 00

RF (SKIP TO E27) 98

DK (SKIP TO E27) 99










IF E24 = 02, SKIP TO E26.




E25.

E26A.

E26B.

COMPLETE ONE ROW FOR EACH TEST/TREATMENT.

What part of your body was tested or treated?



#1:

#2:

During which month between (-3) and (DOIB/END BF) was the (TEST/ TREATMENT) done?

VERBATIM:


Would you say the (TEST/ TREATMENT) was done in the three months before you became pregnant, from (-3) to (-1)?

TEST/TREATMENT:

#1:

N/A (SKIP) 97

RF 98

DK 99

-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

01

02

97

98

99




IF DK, ASK B-F.








#1:

#2:

VERBATIM:







#2:

N/A (SKIP) 97

RF 98

DK 99

-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

01

02

97

98

99




IF DK, ASK B-F.








#1:

#2:

VERBATIM:







#3:

N/A (SKIP) 97

RF 98

DK 99

-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

01

02

97

98

99




IF DK, ASK B-F.












E28.

Between (-3) and (DOIB/END BF) did you have any of the following procedures not related to your pregnancy with (CHILD)? READ ANSWERS AND CODE ALL THAT APPLY.


X-rays, including dental 01

Mammogram 02

CT/CAT scans 03

MRI/magnetic resonance 04

Imaging 05

Radionuclide study or scan 06

Radiation treatments 07

Other x-rays or scans 08

Other (SPECIFY IN GRID) 90

NONE 00

RF 98

DK 99






IF E28 = 02, SKIP TO E30.







IF R DID NOT BREASTFEED, SKIP TO NEXT TEST/E27.

E26C.

E26D.

E26E.

E26F.

Would you say the (TEST/ TREATMENT) was done in your first trimester, from (1) to (3)?

Would you say the (TEST/ TREATMENT) was done in your second trimester, from (4) to (6)?

Would you say the (TEST/ TREATMENT) was done in your third trimester, from (7) to (10)?

VERBATIM:


Would you say the (TEST/ TREATMENT) was done during the months you breastfed, from (DOIB/10) to (END BF)?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99
















VERBATIM:







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99






IF E26 = 98, SKIP TO NEXT PROCEDURE/E28.

IF DK, ASK B-F.









VERBATIM:







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99






IF E26 = 98, SKIP TO NEXT PROCEDURE/E28.

IF DK, ASK B-F.






# OF NON-PREGNANCY TEST/TREATMENT SUPPLEMENTS



MEDICATION USE






I will ask you about medications that you might have taken for specific conditions and symptoms from (-3) through (DOIB/END BF).





E27.

Between (-3) and (DOIB/END BF) did you take any medications or have any other type of treatment such as counseling, behavioral therapy, or physical therapy for the following conditions? READ ANSWERS AND CODE ALL THAT APPLY. DESCRIBE EACH CONDITION WHERE INDICATED.






Acne 01

Allergy 1: 02

Allergy 2: 03

Anxiety disorder 04

Arthritis 05

Asthma 06

Attention Deficit Hyperactivity Disorder 07

Autoimmune disorders (see List 8 in prep guide) 08

Back pain 09

Bipolar disorder 10

Cancer 11

Cardiovascular condition 1: 12

Cardiovascular condition 2: 13

Cold or cough 14

Constipation 15

Depression 16

Diabetes 17

Dieting 18

Eating disorder 1: 19

Eating disorder 2: 20

Eczema or Psoriasis 21

Endocrine disorder 1: 22

Endocrine disorder 2: 23

Gastrointestinal disorder 1: 24

Gastrointestinal disorder 2: 25

General headaches 26

Heartburn 27

High blood pressure 28

Migraine headaches 29

Neuromuscular disorder 1: 30

Neuromuscular disorder 2: 31

Nicotine addiction 32

Obesity 33

Obsessive compulsive disorder 34

Personality disorder 35

Respiratory condition 1: 36

Respiratory condition 2: 37

Schizophrenia 38

Seizures 39

Sickle cell anemia 40

Sleep disorder 41

Thyroid disease 42

Other (SPECIFY) 90

NONE (SKIP TO E30) 00

RF (SKIP TO E30) 98

DK (SKIP TO E30) 99


SPECIFY:


SPECIFY:


SPECIFY:





ANSWER E28–E29 FOR EACH CONDITION.

















PAGE INTENTIONALLY LEFT BLANK



CONDITION 1:


E28.

ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine or other treatment were you given for (CONDITION)? RECORD NAME OF MEDS IN GRID BELOW. Anything else?


PROVIDED NAME OF MED(S)/TREATMENT(S) 01

N/A (SKIP) 97

RF 98

DK 99




E29A.

E29B.

E 29C.

MEDICINE/TREATMENT:

Between (-3) to (DOIB/END BF), which months did you take/have (MEDICINE/ TREATMENT) for (CONDITION)?

Would you say you took/had (MED/TREATMENT) in the three months before you became pregnant, from (-3) to (-1)?

Would you say you took/had (MEDICINE/TREATMENT) in your first trimester, from (1) to (3)?

#1:

E29A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















#2:

E29A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.












CONDITION 2:


E28.

ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine or other treatment were you given for (CONDITION)? RECORD NAME OF MEDS/TREATMENTS IN GRID BELOW. Anything else?


PROVIDED NAME OF MED(S)/TREATMENT(S) 01

N/A (SKIP) 97

RF 98

DK 99



M EDICINE/TREATMENT:

E29A.

E29B.

E29C.

#1:

E29A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















#2:

E29A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.



















IF R DID NOT BREASTFEED, SKIP TO
NEXT MED/NEXT CONDITION/E30.



E29D.

E29E.

E29F.


Would you say you /had (MEDICINE/TREATMENT) in your second trimester, from (4) to (6)?

Would you say you /had (MEDICINE/TREATMENT) in your third trimester, from (7) to (10)?

Would you say you /had (MEDICINE/TREATMENT) during the months you breastfed, from (DOIB/10) to (END BF)?


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99




YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99



# OF NON-PREGNANCY CONDITION 1 MEDICINE SUPPLEMENTS





IF R DID NOT BREASTFEED, SKIP TO
NEXT MED/NEXT CONDITION/E30.






E29D.

E29E.

E29F.


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99



# OF NON-PREGNANCY CONDITION 2 MEDICINE SUPPLEMENTS

CONDITION 3:


E28.

ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine or other treatment were you given for (CONDITION)? RECORD NAME OF MEDS/TREATMENTS IN GRID BELOW. Anything else?


PROVIDED NAME OF MED(S)/TREATMENT(S) 01

N/A (SKIP) 97

RF 98

DK 99




E29A.

E29B.

E 29C.

MEDICINE/TREATMENT:

Between (-3) to (DOIB/END BF), which months did you take/have (MEDICINE/TREATMENT) for (CONDITION)?

Would you say you took/had (MED/TREATMENT) in the three months before you became pregnant, from (-3) to (-1)?

Would you say you took/had (MEDICINE/TREATMENT) in your first trimester, from (1) to (3)?

#1:

E29A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















#2:

E29A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.












CONDITION 4:


E28.

ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine or other treatment were you given for (CONDITION)? RECORD NAME OF MEDS/TREATMENTS IN GRID BELOW. Anything else?


PROVIDED NAME OF MED(S)/TREATMENT(S) 01

N/A (SKIP) 97

RF 98

DK 99



M EDICINE/TREATMENT:

E29A.

E29B.

E29C.

#1:

E29A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















#2:

E29A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.



















IF R DID NOT BREASTFEED, SKIP TO
NEXT MED/NEXT CONDITION/E30.



E29D.

E29E.

E29F.


Would you say you took/had (MEDICINE/TREATMENT) in your second trimester, from (4) to (6)?

Would you say you took/had (MEDICINE/TREATMENT) in your third trimester, from (7) to (10)?

Would you say you took/had (MEDICINE/TREATMENT) during the months you breastfed, from (DOIB/10) to (END BF)?


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99








YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99



# OF NON-PREGNANCY CONDITION 3 MEDICINE SUPPLEMENTS




IF R DID NOT BREASTFEED, SKIP TO
NEXT MED/NEXT CONDITION/E30.






E29D.

E29E.

E29F.


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99








YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99



# OF NON-PREGNANCY CONDITION 4 MEDICINE SUPPLEMENTS


CONDITION 5:


E28.

ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine or other treatment were you given for (CONDITION)? RECORD NAME OF MEDS/TREATMENTS IN GRID BELOW. Anything else?


PROVIDED NAME OF MED(S)/TREATMENT(S) 01

N/A (SKIP) 97

RF 98

DK 99




E29A.

E29B.

E 29C.

MEDICINE/TREATMENT:

Between (-3) to (DOIB/END BF), which months did you take/have (MED/TREAT) for (CONDITION)?

Would you say you took/had (MED/TREAT) in the three months before you became pregnant, from (-3) to (-1)?

Would you say you took/had (MEDICINE/TREATMENT) in your first trimester, from (1) to (3)?

#1:

E29A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















#2:

E29A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.














CONDITION 6:


E28.

ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine or other treatment were you given for (CONDITION)? RECORD NAME OF MEDS/TREATMENTS IN GRID BELOW. Anything else?


PROVIDED NAME OF MED(S)/TREATMENT(S) 01

N/A (SKIP) 97

RF 98

DK 99



M EDICINE/TREATMENT:

E29A.

E29B.

E29C.

#1:

E29A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.















#2:

E29A VERBATIM:


-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99




IF DK, ASK B-F.



















IF R DID NOT BREASTFEED, SKIP TO
NEXT MED/NEXT CONDITION/E30.



E29D.

E29E.

E29F.


Would you say you took/had (MEDICINE/TREATMENT) in your second trimester, from (4) to (6)?

Would you say you took/had (MEDICINE/TREATMENT) in your third trimester, from (7) to (10)?

Would you say you took/had (MED/TREAT) during the months you breastfed, from (DOIB/10) to (END BF)?


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99








YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99



# OF NON-PREGNANCY CONDITION 5 MEDICINE SUPPLEMENTS





IF R DID NOT BREASTFEED, SKIP TO
NEXT MED/NEXT CONDITION/E30.






E29D.

E29E.

E29F.


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99








YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99



# OF NON-PREGNANCY CONDITION 6 MEDICINE SUPPLEMENTS



# OF NON-PREGNANCY CONDITION SUPPLEMENTS




VACCINATIONS



E30.

Now I am going to ask you a few questions about vaccinations. During the time from (-3) to (DOIB/END BF) did you have any vaccinations or shots?


YES 01

NO (SKIP TO F1) 02

RF (SKIP TO F1) 98

DK (SKIP TO F1) 99





E31.

What vaccination did you receive? Was it (READ ANSWERS AND CODE ALL THAT APPLY)?


Combined measles, mumps and rubella vaccine, or MMR 01

Single rubella vaccine 02

Single mumps vaccine 03

Single measles vaccine 04

Tetanus 05

Influenza or flu vaccine 06

Hepatitis A 07

Hepatitis B 08

Allergy shots 09

Other (SPECIFY IN GRID) 90

N/A (SKIP) 97

RF 98

DK 99



E32A.

E32B.

E32C.

COMPLETE ONE ROW FOR EACH VACCINATION.

During which months from
(-3) to (DOIB/END BF) did you receive the (VACCINATION/SHOT)?

Would you say you received (SHOT) in the 3 months before you became pregnant, from (-3) to (-1)?

Would you say you received (SHOT) in your first trimester, from (1) to (3)?








YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#1:

E32A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#2:

E32A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#3:

E32A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.




ORAL/DENTAL DISEASE







E11.

Between (-3) and (DOIB/END BF) did a doctor or dentist ever tell you that you had gingivitis or periodontitis?


YES 01

NO (SKIP TO E18) 02

RF (SKIP TO E18) 98

DK (SKIP TO E18) 99





E12.

Did you take any medication for gingivitis or periodontitis between (-3) and (DOIB/END BF)?


YES 01

NO (SKIP TO E15) 02

N/A (SKIP) 97

RF (SKIP TO E15) 98

DK (SKIP TO E15) 99





E13.

W

IF R DID NOT BREASTFEED,
SKIP TO NEXT SHOT/E33.

hat medicine did you take? PROBE: Anything else? IF R CAN’T RECALL, READ LIST AND CODE ALL THAT APPLY. IF THESE MEDICATIONS WERE NOT GIVEN, ASK R TO REFER TO LIST 8a IN PREP GUIDE UNDER ANTIBIOTICS AND RECORD MEDICATION BELOW.


Penicillin 01

Clindamycin 02

Metronidazole 03

Minocycline 04

Doxycycline 05

Other (SPECIFY IN GRID) 90

N/A (SKIP) 97

RF 98

DK 99



E32D.

E32E.

E32F.


Would you say you received (SHOT) in your second trimester, from (4) to (6)?

Would you say you received (SHOT) in your third trimester, from (7) to (10)?

Would you say you received (SHOT) during the months you breastfed, from (DOIB/10) to (END BF)?


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99






YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99



# OF VACCINATION SUPPLEMENTS






E33.

Did you have any reactions to the vaccinations that required medical attention?


YES 01

NO (SKIP TO F1) 02

N/A (SKIP) 97

RF (SKIP TO F1) 98

DK (SKIP TO F1) 99


COMPLETE ONE ROW FOR EACH REACTION.




E34.


E35.


Which vaccine(s) caused the reaction? SPECIFY.


What was the reaction? SPECIFY.


#1

N/A (SKIP) 97

RF 98

DK 99




N/A (SKIP) 97

RF 98

DK 99






#2

N/A (SKIP) 97

RF 98

DK 99




N/A (SKIP) 97

RF 98

DK 99






#3

N/A (SKIP) 97

RF 98

DK 99




N/A (SKIP) 97

RF 98

DK 99






# OF VACCINATION REACTION SUPPLEMENTS



SECTION F: OBSTETRIC AND DELIVERY COMPLICATIONS

OBSTETRIC COMPLICATIONS

We are interested in learning about any obstetric and pregnancy conditions that you might have had during your pregnancy with (CHILD).





F1.

ASK R TO LOOK AT LIST 9 IN PREP GUIDE. I am going to read you a list of obstetric and pregnancy conditions. Please tell me if you had any of these conditions during your pregnancy with (CHILD). Did you have (READ ANSWERS AND CODE ALL THAT APPLY)?


Anemia 01

Chorioamnionitis 02

Eclampsia 03

Gestational diabetes 04

HELLP syndrome 05

Hyperemesis 06

Incompetent cervix 07

Low blood pressure that required medical treatment 08

Pregnancy-induced hypertension or preeclampsia 09

Premature rupture of your membranes 10

Pre-term or early labor 11

Vaginal bleeding 12

Other (SPECIFY) 90

NONE (SKIP TO F9) 00

RF (SKIP TO F9) 98

DK (SKIP TO F9) 99






SPECIFY:


SPECIFY:






ANSWER F2–F8 FOR EACH COMPLICATION.




COMPLICATION 1:



F2A.

F2B.

F2C.

F2D.

During which months did you have (COMPLICATION)?


F2 VERBATIM:

Would you say you had (COMPLICATION) in your first trimester, from (1) to (3)?

Would you say you had (COMPLICATION) in your second trimester, from (4) to (6)?

Would you say you had (COMPLICATION) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.








F3.

Did you take any medicine for (COMPLICATION)? (IF YES: ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine did you take? Any others?)


YES (SPECIFY IN GRID) 01

NO (SKIP TO F5) 02

N/A (SKIP) 97

RF (SKIP TO F5) 98

DK (SKIP TO F5) 99





MEDICINE 1:



F4A.

F4B.

F4C.

F4D.

During which months from 1 to 10 did you take (MEDICINE) for (COMPLICATION)?


F4 VERBATIM:

Would you say you took (MEDICINE) in your first trimester, from (1) to (3)?

Would you say you took (MEDICINE) in your second trimester, from (4) to (6)?

Would you say you took (MEDICINE) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.




MEDICINE 2:



F4A.

F4B.

F4C.

F4D.

During which months from 1 to 10 did you take (MEDICINE) for (COMPLICATION)?


F4 VERBATIM:

Would you say you took (MEDICINE) in your first trimester, from (1) to (3)?

Would you say you took (MEDICINE) in your second trimester, from (4) to (6)?

Would you say you took (MEDICINE) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.





# OF PREGNANCY COMPLICATION 1 MEDICINE SUPPLEMENTS






F5.

Did you have any treatments for (COMPLICATION)? This could include bed rest, home remedies, medical procedures, acupuncture, or chiropractic treatment. (IF YES: ASK R TO REFER TO LIST 7p IN PREP GUIDE. What treatment did you have? Any others?)


YES (SPECIFY IN GRID) 01

NO (SKIP TO NEXT COMPLICATION/F7) 02

N/A (SKIP) 97

RF (SKIP TO NEXT COMPLICATION/F7) 98

DK (SKIP TO NEXT COMPLICATION/F7) 99



TREATMENT 1:



F6A.

F6B.

F6C.

F6D.

During which months did you have (TREATMENT)?


F6 VERBATIM:

Would you say you had (TREATMENT) in your first trimester, from (1) to (3)?

Would you say you had (TREATMENT) in your second trimester, from (4) to (6)?

Would you say you had (TREATMENT) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.






TREATMENT 2:



F6A.

F6B.

F6C.

F6D.

During which months did you have (TREATMENT)?


F6 VERBATIM:

Would you say you had (TREATMENT) in your first trimester, from (1) to (3)?

Would you say you had (TREATMENT) in your second trimester, from (4) to (6)?

Would you say you had (TREATMENT) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.





# OF PREGNANCY COMPLICATION 1 TREATMENT SUPPLEMENTS


COMPLICATION 2:



F2A.

F2B.

F2C.

F2D.

During which months did you have (COMPLICATION)?


F2 VERBATIM:

Would you say you had (COMPLICATION) in your first trimester, from (1) to (3)?

Would you say you had (COMPLICATION) in your second trimester, from (4) to (6)?

Would you say you had (COMPLICATION) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.








F3.

Did you take any medicine for (COMPLICATION)? (IF YES: ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine did you take? Any others?)


YES (SPECIFY IN GRID) 01

NO (SKIP TO F5) 02

N/A (SKIP) 97

RF (SKIP TO F5) 98

DK (SKIP TO F5) 99





MEDICINE 1:



F4A.

F4B.

F4C.

F4D.

During which months from 1 to 10 did you take (MEDICINE) for (COMPLICATION)?


F4 VERBATIM:

Would you say you took (MEDICINE) in your first trimester, from (1) to (3)?

Would you say you took (MEDICINE) in your second trimester, from (4) to (6)?

Would you say you took (MEDICINE) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.




MEDICINE 2:



F4A.

F4B.

F4C.

F4D.

During which months from 1 to 10 did you take (MEDICINE) for (COMPLICATION)?


F4 VERBATIM:

Would you say you took (MEDICINE) in your first trimester, from (1) to (3)?

Would you say you took (MEDICINE) in your second trimester, from (4) to (6)?

Would you say you took (MEDICINE) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.





# OF PREGNANCY COMPLICATION 2 MEDICINE SUPPLEMENTS






F5.

Did you have any treatments for (COMPLICATION)? This could include bed rest, home remedies, medical procedures, acupuncture, or chiropractic treatment. (IF YES: ASK R TO REFER TO LIST 7p IN PREP GUIDE. What treatment did you have? Any others?)


YES (SPECIFY IN GRID) 01

NO (SKIP TO NEXT COMPLICATION/F7) 02

N/A (SKIP) 97

RF (SKIP TO NEXT COMPLICATION/F7) 98

DK (SKIP TO NEXT COMPLICATION/F7) 99



TREATMENT 1:



F6A.

F6B.

F6C.

F6D.

During which months did you have (TREATMENT)?


F6 VERBATIM:

Would you say you had (TREATMENT) in your first trimester, from (1) to (3)?

Would you say you had (TREATMENT) in your second trimester, from (4) to (6)?

Would you say you had (TREATMENT) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.






TREATMENT 2:



F6A.

F6B.

F6C.

F6D.

During which months did you have (TREATMENT)?


F6 VERBATIM:

Would you say you had (TREATMENT) in your first trimester, from (1) to (3)?

Would you say you had (TREATMENT) in your second trimester, from (4) to (6)?

Would you say you had (TREATMENT) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.





# OF PREGNANCY COMPLICATION 2 TREATMENT SUPPLEMENTS



COMPLICATION 3:



F2A.

F2B.

F2C.

F2D.

During which months did you have (COMPLICATION)?


F2 VERBATIM:

Would you say you had (COMPLICATION) in your first trimester, from (1) to (3)?

Would you say you had (COMPLICATION) in your second trimester, from (4) to (6)?

Would you say you had (COMPLICATION) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.








F3.

Did you take any medicine for (COMPLICATION)? (IF YES: ASK R TO REFER TO LISTS 7a–7p IN PREP GUIDE. What medicine did you take? Any others?)


YES (SPECIFY IN GRID) 01

NO (SKIP TO F5) 02

N/A (SKIP) 97

RF (SKIP TO F5) 98

DK (SKIP TO F5) 99





MEDICINE 1:



F4A.

F4B.

F4C.

F4D.

During which months from 1 to 10 did you take (MEDICINE) for (COMPLICATION)?


F4 VERBATIM:

Would you say you took (MEDICINE) in your first trimester, from (1) to (3)?

Would you say you took (MEDICINE) in your second trimester, from (4) to (6)?

Would you say you took (MEDICINE) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.




MEDICINE 2:



F4A.

F4B.

F4C.

F4D.

During which months from 1 to 10 did you take (MEDICINE) for (COMPLICATION)?


F4 VERBATIM:

Would you say you took (MEDICINE) in your first trimester, from (1) to (3)?

Would you say you took (MEDICINE) in your second trimester, from (4) to (6)?

Would you say you took (MEDICINE) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.





# OF PREGNANCY COMPLICATION 3 MEDICINE SUPPLEMENTS






F5.

Did you have any treatments for (COMPLICATION)? This could include bed rest, home remedies, medical procedures, acupuncture, or chiropractic treatment. (IF YES: ASK R TO REFER TO LIST 7p IN PREP GUIDE. What treatment did you have? Any others?)


YES (SPECIFY IN GRID) 01

NO (SKIP TO NEXT COMPLICATION/F7) 02

N/A (SKIP) 97

RF (SKIP TO NEXT COMPLICATION/F7) 98

DK (SKIP TO NEXT COMPLICATION/F7) 99



TREATMENT 1:



F6A.

F6B.

F6C.

F6D.

During which months did you have (TREATMENT)?


F6 VERBATIM:

Would you say you had (TREATMENT) in your first trimester, from (1) to (3)?

Would you say you had (TREATMENT) in your second trimester, from (4) to (6)?

Would you say you had (TREATMENT) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.






TREATMENT 2:



F6A.

F6B.

F6C.

F6D.

During which months did you have (TREATMENT)?


F6 VERBATIM:

Would you say you had (TREATMENT) in your first trimester, from (1) to (3)?

Would you say you had (TREATMENT) in your second trimester, from (4) to (6)?

Would you say you had (TREATMENT) in your third trimester, from (7) to (10)?

1 04

4 07

7 10

10 13

DK 99

2 05

5 08

8 11

N/A 97

3 06

6 09

9 12

RF 98

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

98

01

02

97

98

98

01

02

97

98

98




IF DK, ASK B-D.





# OF PREGNANCY COMPLICATION 3 TREATMENT SUPPLEMENTS


# OF PREGNANCY COMPLICATION SUPPLEMENTS


F7.

During your pregnancy with (CHILD), how many pelvic exams did you have?


# OF PELVIC EXAMS

RF 98

DK 99




DELIVERY COMPLICATIONS



F8.

Now I am going to ask you a few questions about the labor and delivery with (CHILD). Were you given medications to help start or augment labor such as pitocin or oxytocin?


YES 01

NO 02

RF 98

DK 99





F9.

Did you receive (READ ANSWERS)? CODE ALL THAT APPLY.


General anesthesia 01

A spinal 02

An epidural 03

Other anesthesia (SPECIFY) 90

No anesthesia 00

RF 98

DK 99


SPECIFY





F10.

What was the method of delivery? READ ANSWERS.


Vaginal (ASK F11) 01

Scheduled cesarean section because you had a previous cesarean section 02

Scheduled cesarean section because your baby was breech 03

Scheduled cesarean section for another reason
(SPECIFY) 04

Emergency cesarean section 05

RF 98

DK 99


SPECIFY






IF F10 NOT EQUAL TO 01, SKIP TO F13.







F11.

Were forceps used or was vacuum extraction done to aide delivery?








YES

NO

N/A
(SKIP)

RF

DK


a. Forceps

01

02

97

98

99


b. Vacuum extraction

01

02

97

98

99





F12.

Was the baby breech?


YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99





F13.

Did you experience any of the following events during the labor or delivery of (CHILD)? READ ANSWERS AND CODE ALL THAT APPLY.


Adverse reaction to anesthesia 01

High fever (ASK F14) 02

Hemorrhage 03

Uterine rupture 04

Low blood pressure 05

Other (SPECIFY) 90

NONE 00

RF 98

DK 99


SPECIFY



IF F13 NOT EQUAL TO 02, SKIP TO F15.






C

F

F14.

What was the highest temperature recorded during your fever?


TEMPERATURE .

N/A (SKIP) 97

RF 98

DK 99





F15.

During or after delivery of (CHILD), did any of the following occur to (CHILD)? READ ANSWERS AND CODE ALL THAT APPLY.


Cord wrapped around neck 01

Failure to progress 02

Fever in (CHILD) 03

Fetal distress 04

Resuscitation needed 05

Sent to neonatal intensive care unit or NICU 06

Needed transfusion 07

Antibiotics given 08

Jaundice (ASK F16) 09

Meconium aspiration 10

Other (SPECIFY) 90

NONE 00

RF 98

DK 99


SPECIFY:






IF F15 NOT EQUAL TO 09, SKIP TO SECTION G.







F16.

Did (CHILD) receive phototherapy or bili lights, bili blanket, or special lights?


YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99


















BLANK PAGE FOR END OF SECTION

SECTION G: POSTNATAL HISTORY






Now I’d like to ask you some questions about (CHILD)’s health after (his/her) birth. You can refer to List 10 in your prep guide for assistance.






MEDICAL CONDITIONS







G1.

ASK R TO REFER TO LIST 10 IN PREP GUIDE. Please tell me if a doctor or other health care professional ever told you that (CHILD) had any of the following conditions or problems between birth and age three, that is, until (CHILD)’s 3rd birthday. Did (CHILD) have (READ ANSWERS AND CODE ALL THAT APPLY)?


Chicken pox 01

Cytomegalovirus 02

Diphtheria 03

Ear infection, recurrent 04

Eczema or Psoriasis 05

German measles or rubella 06

Hepatitis (PROBE)

HEPATITIS A 07

HEPATITIS B 08

HEPATITIS C 09

HEPATITIS NOS 10

Herpes infection 11

HIV 12

Lyme Disease 13

Measles 14

Bacterial meningitis 15

Viral meningitis 16

Mumps 17

Parvovirus or Fifth Disease 18

Pneumonia 19

Respiratory Syncytial Virus or RSV 20

Seizure disorder or Epilepsy 21

Skin condition (SPECIFY) 22

Streptococcus, Group B or Group B Strep 23

Tetanus 24

Tonsillitis 25

Toxoplasmosis 26

Tuberculosis 27

Urinary Tract Infection or UTI 28

Other (SPECIFY) 90

NONE (SKIP TO G7) 00

RF (SKIP TO G7) 98

DK (SKIP TO G7) 99


SPECIFY:


SPECIFY:






ANSWER G2–G6 FOR EACH CONDITION.





G2.

G3.

G 4.

CONDITION:

At what ages did (CHILD) have (INFECTION/CONDITION)? CODE ALL AGES THAT APPLY.

Did (CHILD) take any medication for (INFECTION/CONDITION)?

ASK R TO REFER TO LIST 11a–11g IN PREP GUIDE. What medicine did (CHILD) take for (INFECTION/ CONDITION)? Any other?

#1:

<1 YEAR (BEFORE 1ST BIRTHDAY) 01

2 YEARS (BETWEEN 1ST AND 2ND BIRTHDAY) 02

3 YEARS (BETWEEN 2ND AND 3RD BIRTHDAY) 03

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO (SKIP TO G5) 02

N/A (SKIP) 97

RF (SKIP TO G5) 98

DK (SKIP TO G5) 99


MEDICINE 1:


MEDICINE 2:


MEDICINE 3:

N/A (SKIP) 97

RF 98

DK 99





#2:

<1 YEAR (BEFORE 1ST BIRTHDAY) 01

2 YEARS (BETWEEN 1ST AND 2ND BIRTHDAY) 02

3 YEARS (BETWEEN 2ND AND 3RD BIRTHDAY) 03

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO (SKIP TO G5) 02

N/A (SKIP) 97

RF (SKIP TO G5) 98

DK (SKIP TO G5) 99


MEDICINE 1:


MEDICINE 2:


MEDICINE 3:

N/A (SKIP) 97

RF 98

DK 99





#3:

<1 YEAR (BEFORE 1ST BIRTHDAY) 01

2 YEARS (BETWEEN 1ST AND 2ND BIRTHDAY) 02

3 YEARS (BETWEEN 2ND AND 3RD BIRTHDAY) 03

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO (SKIP TO G5) 02

N/A (SKIP) 97

RF (SKIP TO G5) 98

DK (SKIP TO G5) 99


MEDICINE 1:


MEDICINE 2:


MEDICINE 3:

N/A (SKIP) 97

RF 98

DK 99







G5.

G6.

Did (CHILD) have any treatment for (INFECTION/CONDITION)? This could include bed rest, home remedies, medical procedures, acupuncture, or chiropractic treatment.

ASK R TO REFER TO LIST 11g IN PREP GUIDE. What treatment did (CHILD) have for condition? Anything else?

YES 01

NO (SKIP TO NEXT CONDITION/G7) 02

N/A (SKIP) 97

RF (SKIP TO NEXT CONDITION/G7) 98

DK (SKIP TO NEXT CONDITION/G7) 99


TREATMENT 1:


TREATMENT 2:


TREATMENT 3:

N/A (SKIP) 97

RF 98

DK 99



YES 01

NO (SKIP TO NEXT CONDITION/G7) 02

N/A (SKIP) 97

RF (SKIP TO NEXT CONDITION/G7) 98

DK (SKIP TO NEXT CONDITION/G7) 99


TREATMENT 1:


TREATMENT 2:


TREATMENT 3:

N/A (SKIP) 97

RF 98

DK 99



YES 01

NO (SKIP TO NEXT CONDITION/G7) 02

N/A (SKIP) 97

RF (SKIP TO NEXT CONDITION/G7) 98

DK (SKIP TO NEXT CONDITION/G7) 99


TREATMENT 1:


TREATMENT 2:


TREATMENT 3:

N/A (SKIP) 97

RF 98

DK 99


# OF CHILD MEDICAL CONDITION SUPPLEMENTS




ALLERGIES







G7.

Has a doctor ever told you that (CHILD) had allergies?


YES 01

NO (SKIP TO G13) 02

RF (SKIP TO G13) 98

DK (SKIP TO G13) 99





G8.

Which of the following types of allergies does (CHILD) have? Is it (READ ANSWERS AND CODE ALL THAT APPLY)?


Hay fever 01

Skin allergy (SPECIFY) 02

Food allergy (SPECIFY) 03

Drug allergy (SPECIFY) 04

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:


SPECIFY:


SPECIFY:


SPECIFY:






ANSWER G9–G11 FOR EACH ALLERGY.






G9.

G10.

G11.

ALLERGY:

How old was (CHILD) when you were first told that (he/she) had (ALLERGY)?

Did (CHILD) take any medications for (ALLERGY)?

ASK R TO REFER TO LIST 11a–11g IN PREP GUIDE. What medicines did (CHILD) take? Anything else?


#1:


YEARS

AND/OR

MONTHS

N/A (SKP) 97

RF 98

DK 99


YES 01

NO (SKIP TO NEXT

ALLERGY/G12) 02

N/A (SKIP) 97

RF (SKIP TO NEXT

ALLERGY/G12) 98

DK (SKIP TO NEXT

ALLERGY/G12) 99


MEDICINE 1:


MEDICINE 2:


MEDICINE 3:

N/A (SKIP) 97

RF 98

DK 99






#2:


YEARS

AND/OR

MONTHS

N/A (SKP) 97

RF 98

DK 99


YES 01

NO (SKIP TO NEXT

ALLERGY/G12) 02

N/A (SKIP) 97

RF (SKIP TO NEXT

ALLERGY/G12) 98

DK (SKIP TO NEXT

ALLERGY/G12) 99


MEDICINE 1:


MEDICINE 2:


MEDICINE 3:

N/A (SKIP) 97

RF 98

DK 99






#3:


YEARS

AND/OR

MONTHS

N/A (SKP) 97

RF 98

DK 99


YES 01

NO (SKIP TO NEXT

ALLERGY/G12) 02

N/A (SKIP) 97

RF (SKIP TO NEXT

ALLERGY/G12) 98

DK (SKIP TO NEXT

ALLERGY/G12) 99


MEDICINE 1:


MEDICINE 2:


MEDICINE 3:

N/A (SKIP) 97

RF 98

DK 99


# OF CHILD ALLERGY SUPPLEMENTS






G12.

Has (CHILD) ever had an allergic reaction that required medical attention such as an office contact, either telephone or in-person visit, or hospitalization?


YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99






MEDICATION USE








We are interested in other medications, including over-the-counter medications that (CHILD) might have been given from birth up to (his/her) third birthday. I will ask you about medications that (CHILD) might have taken for specific conditions and symptoms during the first three years of (CHILD)’s life. Please refer to list 11a through 11g in your preparatory guide so that we can get the most accurate information possible. Medications can be in pill form, nasal spray, patches, creams, or any other over the counter medications.





G13.

From birth to (his/her) third birthday, did (CHILD) take any medications for the following conditions? READ ANSWERS AND CODE ALL THAT APPLY.


General headaches 01

Cold 02

Cough 03

Fevers 04

Influenza or flu 05

Asthma 06

Eye infections 07

Gastrointestinal problems with stomach or bowel 08

Sleep disorders 09

Behavior problems 10

Other (SPECIFY) 90

NONE (SKIP TO G16) 00

RF (SKIP TO G16) 98

DK (SKIP TO G16) 99


SPECIFY:



G14.

G15.

ANSWER G14-G15 FOR EACH CONDITION

ASK R TO REFER TO LISTS 11a–11g IN PREP GUIDE. What medicine did (CHILD) take for (CONDITION)? Any others?

At what ages did (CHILD) take (MEDICATION)?


CONDITION 1:


MED 1:

N/A (SKIP) 97

RF (SKIP TO NEXT MED/NEXT CONDITION/G16) 98

DK (SKIP TO NEXT MED/NEXT CONDITION/G16) 99

YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99




MED 2:

N/A (SKIP) 97

RF (SKIP TO NEXT MED/NEXT CONDITION/G16) 98

DK (SKIP TO NEXT MED/NEXT CONDITION/G16) 99

YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99




MED 3:

N/A (SKIP) 97

RF (SKIP TO NEXT MED/NEXT CONDITION/G16) 98

DK (SKIP TO NEXT MED/NEXT CONDITION/G16) 99

YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99


# OF CHILD CONDITION 1 MEDICINE SUPPLEMENTS



G14.

G15.


ASK R TO REFER TO LISTS 11a–11g IN PREP GUIDE. What medicine did (CHILD) take for (CONDITION)? Any others?

At what ages did (CHILD) take (MEDICATION)?


CONDITION 2:


MED 1:

N/A (SKIP) 97

RF (SKIP TO NEXT MED/NEXT CONDITION/G16) 98

DK (SKIP TO NEXT MED/NEXT CONDITION/G16) 99

YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99




MED 2:

N/A (SKIP) 97

RF (SKIP TO NEXT MED/NEXT CONDITION/G16) 98

DK (SKIP TO NEXT MED/NEXT CONDITION/G16) 99

YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99




MED 3:

N/A (SKIP) 97

RF (SKIP TO NEXT MED/NEXT CONDITION/G16) 98

DK (SKIP TO NEXT MED/NEXT CONDITION/G16) 99

YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99


# OF CHILD CONDITION 2 MEDICINE SUPPLEMENTS



G14.

G15.


ASK R TO REFER TO LISTS 11a–11g IN PREP GUIDE. What medicine did (CHILD) take for (CONDITION)? Any others?

At what ages did (CHILD) take (MEDICATION)?


CONDITION 3:


MED 1:

N/A (SKIP) 97

RF (SKIP TO NEXT MED/NEXT CONDITION/G16) 98

DK (SKIP TO NEXT MED/NEXT CONDITION/G16) 99

YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99




MED 2:

N/A (SKIP) 97

RF (SKIP TO NEXT MED/NEXT CONDITION/G16) 98

DK (SKIP TO NEXT MED/NEXT CONDITION/G16) 99

YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99




MED 3:

N/A (SKIP) 97

RF (SKIP TO NEXT MED/NEXT CONDITION/G16) 98

DK (SKIP TO NEXT MED/NEXT CONDITION/G16) 99

YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99



YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99


# OF CHILD CONDITION 3 MEDICINE SUPPLEMENTS



INJURIES







G16.

Has (CHILD) ever had an injury that required medical attention?


YES 01

NO (SKIP TO H1) 02

RF (SKIP TO H1) 98

DK (SKIP TO H1) 99


COMPLETE G17–G24 FOR EACH INJURY.




G17.

G18.

G19.

G20.

G21.

G 22.

What was the injury?




INJURY

How old was (CHILD) when (INJURY) happened?

Did (CHILD) lose consciousness as a result of (INJURY)?

Was (CHILD) hospitalized or did (he/she) visit an emergency room for (INJURY)?

Was surgery performed on (CHILD) for (INJURY)?

Did (CHILD) take any medications or receive injections because of the (INJURY)?


#1:


N/A (SKIP) 97

RF 98

DK 99

YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO (SKIP TO

G24) 02

N/A (SKIP) 97

RF (SKIP TO

G24) 98

DK (SKIP TO

G24) 99


#2:


N/A (SKIP) 97

RF 98

DK 99

YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO (SKIP TO

G24) 02

N/A (SKIP) 97

RF (SKIP TO

G24) 98

DK (SKIP TO

G24) 99


#3:


N/A (SKIP) 97

RF 98

DK 99

YEARS

AND/OR

MONTHS

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO (SKIP TO

G24) 02

N/A (SKIP) 97

RF (SKIP TO

G24) 98

DK (SKIP TO

G24) 99




INJURIES







I16.

Has (CHILD) ever had an injury that required medical attention?


YES 01

NO (SKIP TO J1) 02

RF (SKIP TO J1) 98

DK (SKIP TO J1) 99


COMPLETE I17–I24 FOR EACH INJURY.




G23.

G24.

ASK R TO REFER TO LIST 11a–11g IN PREP GUIDE. What medications or injections did (CHILD) take or receive for (INJURY)? Any others?

Did your child have any long-term or significant changes in behavior after (INJURY)?

MED #1:

MED #2:

MED #3:

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

MED #1:

MED #2:

MED #3:

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

MED #1:

MED #2:

MED #3:

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO 02

N/A (SKIP) 97

RF 98

DK 99

# OF CHILD INJURY SUPPLEMENTS

















BLANK PAGE FOR END OF SECTION



SECTION H: OCCUPATIONAL HISTORY


IF R NOT BIOMOM (A5 > 01), SKIP TO SECTION K.







Now, I am going to ask you about your work experience during the 3 months before you became pregnant until ([CHILD] was born/time you stopped breastfeeding [CHILD]), so that would include (-3) to (DOIB/END BF). As we discuss your jobs, please include jobs that were paid, volunteer, or military service, which lasted one month or more for 10 or more hours per week. I will also ask you about stay-at-home parenting and education activities, so do not include those as a job.





H1A.

Between (-3) and (DOIB/END BF) did you have a job?


YES 01

NO 02

RF 98

DK 99





H1B.

During that time, were you enrolled as a regular full-time student? That is, not just taking 1 class or community classes.


YES 01

NO (SKIP TO H3) 02

RF (SKIP TO H3) 98

DK (SKIP TO H3) 99





H1C.

At what level or grade were you enrolled?


HS OR VOCATIONAL SCHOOL (SKIP TO H2A) 01

COLLEGE–UNDERGRAD 02

GRAD OR PROFESSIONAL SCHOOL 03

N/A (SKIP) 97

RF (SKIP TO H2A) 98

DK (SKIP TO H2A) 99





H1D.

What was your major field of study? SPECIFY.


MAJOR:

N/A (SKIP) 97

RF 98

DK 99





H2A.

H2B.

H2C.

H2D.

During which months from
(-3) to (DOIB/END BF) were you a regular student?


VERBATIM:

Would you say you were a regular student in the three months before you became pregnant, from (-3) to (-1)?

Would you say you were a regular student in your first trimester, from (1) to (3)?

Would you say you were a regular student in your second trimester, from (4) to (6)?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99

IF DK, ASK B-F. OTHERWISE, SKIP TO H4 BOX.




IF R DID NOT BREASTFEED,
SKIP TO H4 BOX.




H2E.

H2F.

Would you say you were a regular student in your third trimester, from (7) to (10)?

Would you say you were a regular student during the months you breastfed, from (DOIB/10) to (END BF)?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99








IF HAD A JOB (H1A = 01), SKIP TO H4 BOX.







H3A.

Which of the following describes what you were doing during this time? Were you (READ ANSWERS AND CODE ALL THAT APPLY)?


A stay at home parent or caregiver 01

Disabled 02

Unemployed or in between jobs (ASK H3B) 03

Incarcerated 04

Something else? (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:






IF H3A NOT EQUAL TO 03, SKIP TO SECTION J.







H3B.

What was your usual job or job title?


SPECIFY:

N/A (SKIP) 97

RF 98

DK 99








SKIP TO SECTION J.


H4 INSTRUCTION BOX:







IF STUDENT ONLY (H1A = 02, 98, OR 99), SKIP TO H10.










I would like to know more about the jobs that you held between (-3) and (DOIB/END BF) that lasted one month or more at 10 or more hours a week. I am interested in types of jobs, so if you worked different jobs with the same employer, please tell me about those as separate jobs. But if you were self-employed or a contractor doing similar work for different companies, include that as one job. Think about all the jobs you had between (-3) and (DOIB/END BF) starting with the most recent.








ASK H4A-C FOR ALL JOBS, THEN ANSWER
H5-H9 FOR EACH JOB.























PAGE INTENTIONALLY LEFT BLANK



H 4A.

H4B.

H4C.

H5.

Can you please tell me your title for the most recent job? This would be the one you had just after (CHILD) was born. And your title for the previous job?

Please tell me the name of the company or organization you worked for, or whether you were self-employed, for this (most recent/previous) job.

Please tell me the city and state the job was located in, for this (most recent/previous) job.

Next, I’m going to ask you a few questions about each of those jobs. For your job as (JOB TITLE), when did you start working at this job? Please tell me the month and year.

JOB TITLE:

EMPLOYER:

CITY/STATE:

MONTH / YEAR:

1.

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

/

N/A (SKIP) 97

RF 98

DK 99

2.

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

/

N/A (SKIP) 97

RF 98

DK 99

3.

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

/

N/A (SKIP) 97

RF 98

DK 99

4.

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

/

N/A (SKIP) 97

RF 98

DK 99

5.

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

/

N/A (SKIP) 97

RF 98

DK 99



H6.

H7.

H8.

H9.

When did you stop working at this job? Please tell me the month and year.

How many hours per week did you work on this job?

What type of business was this, or what did the company make or do?

Please describe your main duties or activities for this job, that is what you did and how you did it. PROBE: Anything else?

MONTH / YEAR:

HOURS PER WEEK:

BUSINESS:

MAIN DUTIES:

/

N/A (SKIP) 97

RF 98

DK 99

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

/

N/A (SKIP) 97

RF 98

DK 99

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

/

N/A (SKIP) 97

RF 98

DK 99

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

/

N/A (SKIP) 97

RF 98

DK 99

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

/

N/A (SKIP) 97

RF 98

DK 99

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

1

N/A (SKIP) 97

RF 98

DK 99

# OF JOB SUPPLEMENTS






H10.

(At any of these jobs/[or] As a student), did you regularly, that is a least once per week from (-3) to (DOIB/END BF), work with or around any substances or chemicals? Please include substances such as solvents or degreasers, pesticides, heavy metals, or radioactive materials including x-rays.


YES 01

NO (SKIP TO J1) 02

N/A (SKIP) 97

RF (SKIP TO J1) 98

DK 99






ASK R TO REFER TO LIST 12 IN PREP GUIDE. I would like to ask you more about the chemicals or substances that you may have used. Some of the names may not sound familiar to you, but answer as best you can.





H11A.

Did you work with or around any of the following at least once per week, from (-3) to (DOIB/END BF), at any job you described (or at school)? READ ANSWERS AND CODE ALL THAT APPLY.






Adhesives or glues, like rubber cement 01

Alcohols, such as methanol or ethanol 02

Anesthetic gases 03

Automotive fluids (PROBE)* 04

Antifreeze 05

Brake fluid 06

Degreasers 07

Freon 08

Gasoline 09

Benzene 10

Carbon disulfide 11

Carbon tetrachloride 12

Diesel fumes 13

Ethylene oxide 14

Glycol ethers 15

Lacquers 16

Metals (PROBE)* 17

Chromium 18

Lead 19

Manganese 20

Mercury 21

Metal dust or fumes 22

Nickel 23

Other metals (SPECIFY) 24

Oil-based paints 25

Paint strippers 26

Paint thinners 27

Perchlorethylene or perc 28

Pesticides or herbicides, for example bug or weed killers (PROBE)* 29

Fungicides (SPECIFY) 30

Herbicides (SPECIFY) 31

Insecticides (SPECIFY) 32

Rat poison (SPECIFY) 33

Pharmaceuticals or drugs 34

Phthalates 35

Styrene 36

Toluene 37

Trichloroethylene or TCE or trichlorethane or TCA 38

Varnishes 39

Vinyl chloride 40

X-ray or radioactive materials 41

Xylene 42

Any other solvents or
degreasers (SPECIFY) 43

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99


SPECIFY:


SPECIFY:


SPECIFY:


SPECIFY:


* ASK ALL SPECIFIC INDENTED CHEMICALS/SUBSTANCES EVEN IF CATEGORY ANSWER IS NO.













PAGE INTENTIONALLY LEFT BLANK

H11B.

H11C.

H 11D.

COMPLETE ONE ROW FOR EACH CHEMICAL OR SUBSTANCE USED.

Which months between (-3) and (DOIB/END BF) were you around (CHEM/ SUBSTANCE)?

Would you say you were around (CHEM/SUBSTANCE) in the three months before you became pregnant, from (-3) to (-1)?

Would you say you were around (CHEM/SUBSTANCE) in your first trimester, from (1) to (3)?

CHEMICAL/SUBSTANCE:







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#1:

H11B VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK C–G. OTHERWISE, SKIP TO H12A.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#2:

H11B VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK C–G. OTHERWISE, SKIP TO H12A.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#3:

H11B VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK C–G. OTHERWISE, SKIP TO H12A.





IF R DID NOT BREASTFEED, SKIP TO NEXT CHEM/SUBSTANCE/H12A.



H11E.

H11F.

H11G.

Would you say you were around (CHEM/SUBSTANCE) in your second trimester, from (4) to (6)?

Would you say you were around (CHEM/SUBSTANCE) in your third trimester, from (7) to (10)?

Would you say you were around (CHEM/SUBSTANCE) during the months you breastfed, from (DOIB/10) to (END BF)?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


IF DK, ASK C–G. OTHERWISE, SKIP TO J12A.


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


IF DK, ASK C–G. OTHERWISE, SKIP TO J12A.


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99





H12A.

H12B.

H12C.

H12D.

Please describe the activities you were doing around these substances you mentioned (at which job), including how often you were around them.

Did you work mostly indoors, outdoors, or both?

When you were around these, did you usually use any protective gear or equipment such as gloves, masks, respirators, or fume hoods?

Which did you use? READ ANSWERS AND CODE ALL THAT APPLY.

VERBATIM:

N/A (SKIP) 97

RF 98

DK 99

INDOORS 01

OUTDOORS 02

BOTH 03

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO (SKIP TO NEXT

SUBSTANCE/J1) 02

N/A (SKIP) 97

RF 98

DK 99

Gloves or protective clothing 01

Goggles 02

Mask 03

Respirator 04

Fume hood or local ventilation 05

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99

SPECIFY:


IF DK, ASK C–G. OTHERWISE, SKIP TO J12A.



VERBATIM:

N/A (SKIP) 97

RF 98

DK 99

INDOORS 01

OUTDOORS 02

BOTH 03

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO (SKIP TO NEXT

SUBSTANCE/J1) 02

N/A (SKIP) 97

RF 98

DK 99

Gloves or protective clothing 01

Goggles 02

Mask 03

Respirator 04

Fume hood or local ventilation 05

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99

SPECIFY:


IF DK, ASK C–G. OTHERWISE, SKIP TO J12A.



VERBATIM:

N/A (SKIP) 97

RF 98

DK 99

INDOORS 01

OUTDOORS 02

BOTH 03

N/A (SKIP) 97

RF 98

DK 99

YES 01

NO (SKIP TO NEXT

SUBSTANCE/J1) 02

N/A (SKIP) 97

RF 98

DK 99

Gloves or protective clothing 01

Goggles 02

Mask 03

Respirator 04

Fume hood or local ventilation 05

Other (SPECIFY) 90

N/A (SKIP) 97

RF 98

DK 99

SPECIFY:


# OF CHEMICAL/SUBSTANCE SUPPLEMENTS















UNFOLD PAGE FOR 3-PAGE TABLE















BLANK PAGE FOR END OF SECTION




SECTION J: TOBACCO, ALCOHOL, AND OTHER DRUGS







TOBACCO







J1.

The next several questions are about your lifestyle. Did you ever smoke cigarettes?


YES 01

NO (SKIP TO J5) 02

RF (SKIP TO J5) 98

DK (SKIP TO J5) 99





J2.

At any time from (-3) to (DOIB/END BF), did you smoke cigarettes?


YES 01

NO (SKIP TO J5) 02

N/A (SKIP) 97

RF (SKIP TO J5) 98

DK (SKIP TO J5) 99






J3A.

J3B.

J3C.


During which months did you smoke?

Did you smoke in the three months before you became pregnant, from (-3) to (-1)?

Did you smoke in your first trimester, from (1) to (3)?







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

J3A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.





IF R DID NOT BREASTFEED, SKIP TO J4.






J3D.

J3E.

J3F.


Did you smoke in your second trimester, from (4) to (6)?

Did you smoke in your third trimester, from (7) to (10)?

Did you smoke during the months you breastfed, from (DOIB/10) to (END BF)?



YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99








COMPLETE ONE ROW FOR EACH MONTH/TRIMESTER INDICATED.






J4.

About how many cigarettes did you smoke a day during (MONTH/TRIMESTER)?


MONTH/TRIMESTER

<1/

day

1/day

2-4/ day

½ Pack

(5-14)

1 Pack

(15-24)

1½ Packs

(25-34)

2 Packs

(35-44)

>2 Packs

N/A (SKIP)

RF

DK


1.

01

02

03

04

05

06

07

08

97

98

99


2.

01

02

03

04

05

06

07

08

97

98

99


3.

01

02

03

04

05

06

07

08

97

98

99


4.

01

02

03

04

05

06

07

08

97

98

99


5.

01

02

03

04

05

06

07

08

97

98

99


6.

01

02

03

04

05

06

07

08

97

98

99


7.

01

02

03

04

05

06

07

08

97

98

99


8.

01

02

03

04

05

06

07

08

97

98

99


9.

01

02

03

04

05

06

07

08

97

98

99


10.

01

02

03

04

05

06

07

08

97

98

99


11.

01

02

03

04

05

06

07

08

97

98

99


12.

01

02

03

04

05

06

07

08

97

98

99


13.

01

02

03

04

05

06

07

08

97

98

99


14.

01

02

03

04

05

06

07

08

97

98

99





J5.

At any time from (-3) to (DOIB/END BF), did you use other tobacco products? (PROMPT: chewing tobacco, pipe tobacco, cigar smoking).


YES 01

NO 02

RF 98

DK 99





J6.

Did anyone else smoke one or more cigarettes regularly in your home between (-3) and (DOIB/END BF)?


YES 01

NO (SKIP TO K1) 02

RF (SKIP TO K1) 98

DK (SKIP TO K1) 99




J7A.

J7B.

J7C.


During which months from
(-3) to (DOIB/END BF), did someone else smoke cigarettes in your home?

Would you say someone else smoked cigarettes in your home during the three months before you became pregnant, from (-3) to (-1)?

Would you say someone else smoked cigarettes in your home during your first trimester, from (1) to (3)?







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

J7A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.





IF R DID NOT BREASTFEED, SKIP TO J8.






J7D.

J7E.

J7F.


Would you say someone else smoked cigarettes in your home during your second trimester, from (4) to (6)?

Would you say someone else smoked cigarettes in your home during your third trimester, from (7) to (10)?

Would you say someone else smoked cigarettes in your home during the months you breastfed, from (DOIB/10) to (END BF)?



YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99








ALCOHOL



J8.

Did you have any alcoholic drinks between (-3) and (DOIB/END BF)? We define an alcoholic drink as one beer, one glass of wine, one mixed drink, or one shot of liquor.


YES 01

NO (SKIP TO J13) 02

RF (SKIP TO J13) 98

DK (SKIP TO J13) 99






J9A.

J9B.

J9C.


During which months did you drink?

Would you say you drank in the three months before you became pregnant, from (-3) to (-1)?

Would you say you drank in your first trimester, from (1) to (3)?

J9A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.





IF R DID NOT BREASTFEED, SKIP TO J10.






J9D.

J9E.

J9F.


Would you say you drank in your second trimester, from (4) to (6)?

Would you say you drank in your third trimester, from (7) to (10)?

Would you say you drank during the months you breastfed, from (DOIB/10) to (END BF)?



YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99



COMPLETE ONE ROW FOR EACH MONTH/TRIMESTER INDICATED.






J10.

During (MONTH/TRIMESTER), on average, how many drinks did you have per week?


MONTH/TRIMESTER

<1/

Week

1 or 2

3 or 4

5 or 6

6 or 7

7 to 9

10 or more

N/A (SKIP)

RF

DK


1.

01

02

03

04

05

06

07

97

98

99


2.

01

02

03

04

05

06

07

97

98

99


3.

01

02

03

04

05

06

07

97

98

99


4.

01

02

03

04

05

06

07

97

98

99


5.

01

02

03

04

05

06

07

97

98

99


6.

01

02

03

04

05

06

07

97

98

99


7.

01

02

03

04

05

06

07

97

98

99


8.

01

02

03

04

05

06

07

97

98

99


9.

01

02

03

04

05

06

07

97

98

99


10.

01

02

03

04

05

06

07

97

98

99


11.

01

02

03

04

05

06

07

97

98

99


12.

01

02

03

04

05

06

07

97

98

99


13.

01

02

03

04

05

06

07

97

98

99


14.

01

02

03

04

05

06

07

97

98

99






J11.

Were there times when you had five or more drinks on one occasion between (-3) and (DOIB/END BF)?


YES 01

NO (SKIP TO J13) 02

N/A (SKIP) 97

RF (SKIP TO J13) 98

DK (SKIP TO J13) 99







J12A.

J12B.

J12C.


During which months from
(-3) to (DOIB/END BF), did you drink five or more drinks on one occasion?

Would you say you drank five or more drinks on one occasion during the three months before you became pregnant, from (-3) to (-1)?

Would you say you drank five or more drinks on one occasion during your first trimester, from (1) to (3)?







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

J12A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B-F.





IF R DID NOT BREASTFEED, SKIP TO J13.






J12D.

J12E.

J12F.


Would you say you drank five or more drinks on one occasion during your second trimester, from (4) to (6)?

Would you say you drank five or more drinks on one occasion during your third trimester, from (7) to (10)?

Would you say you drank five or more drinks on one occasion during the months you breastfed, from (DOIB/10) to (END BF)?



YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK


01

02

97

98

99

01

02

97

98

99

01

02

97

98

99







OTHER DRUGS







J13.

Now I would like to ask you about any recreational drugs you might have used. Between (-3) and (DOIB/BF) did you use any of the following recreational or street drugs, or any prescription drugs that were not prescribed to you? READ ANSWERS AND CODE ALL THAT APPLY.


Marijuana 01

Cocaine 02

Ecstasy 03

Methamphetamines or crank or ice 04

Other (SPECIFY) 90

NONE (SKIP TO K1) 00

RF (SKIP TO K1) 98

DK (SKIP TO K1) 99






SPECIFY:



J14A.

J14B.

J 14C.

COMPLETE ONE ROW FOR EACH DRUG USED.

Which months between (-3) and (DOIB/END BF) did you use or take (DRUG)?

Would you say you used or took (DRUG) in the three months before you became pregnant, from (-3) to (-1)?

Would you say you used or took (DRUG) in your first trimester, from (1) to (3)?

DRUG:







YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#1:

J14A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B–F. OTHERWISE, SKIP TO K1.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#2:

J14A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B–F. OTHERWISE, SKIP TO K1.









YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

#3:

J14A VERBATIM:



-3 01

1 04

4 07

7 10

10 13

RF 98

-2 02

2 05

5 08

8 11

BF 14

DK 99

-1 03

3 06

6 09

9 12

N/A 97

01

02

97

98

99

01

02

97

98

99


IF DK, ASK B–F. OTHERWISE, SKIP TO K1.





IF R DID NOT BREASTFEED, SKIP TO NEXT DRUG/K1.



J14D.

J14E.

J14F.

Would you say you used or took (DRUG) in your second trimester, from (4) to (6)?

Would you say you used or took (DRUG) in your third trimester, from (7) to (10)?

Would you say you used or took (DRUG) during the months you breastfed, from (DOIB/10) to (END BF)?

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


IF DK, ASK C–G. OTHERWISE, SKIP TO J12A.


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


IF DK, ASK C–G. OTHERWISE, SKIP TO J12A.


YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

YES

NO

N/A

RF

DK

01

02

97

98

99

01

02

97

98

99

01

02

97

98

99


# OF DRUG SUPPLEMENTS















BLANK PAGE FOR END OF SECTION




SECTION K: INCOME AND CLOSING





K1.

The final survey questions ask about household income. In the 12 months prior to when (you were/[CHILD]’s biological mother was) pregnant with (CHILD), what was (your/her) estimated total household income before taxes? Please include income such as Medicaid, Social Security, and Unemployment payments. Was it (READ ANSWERS)?


Less than 10 Thousand Dollars 01

10 to 30 Thousand Dollars 02

30 to 50 Thousand Dollars 03

50 to 70 Thousand Dollars 04

70 to 90 Thousand Dollars 05

90 to 110 Thousand Dollars 06

More than 110 Thousand Dollars 07

RF 98

DK 99






INTERVIEWER NOTE: If income is exactly as start/end point, round up to the high range. For example, if income = $30,000, round up to 30-50,000.





K2.

At that time, how many people were living in the household, including both adults and children?


# OF PEOPLE

RF 98

DK 99






A. How many of these were children under the age of 18?


# OF CHILDREN

RF 98

DK 99





K3.

Do you currently live with (CHILD)? (PROBE: How much of the time do you live with [CHILD])?


YES, ALL OF THE TIME 01

YES, PART OF THE TIME/SHARED CUSTODY (ASK A) 02

NO, NONE OF THE TIME 03

RF 98

DK 99






IF K3 NOT EQUAL TO 02, SKIP TO K4.








A. On average, how many days does (CHILD) live with you?


NUMBER OF DAYS

PER WEEK 1

PER MONTH 2

PER YEAR 3

N/A (SKIP) 97

RF 98

DK 99





K4.

What was your estimated total household income for the last 12 months before taxes? Please include income such as Medicaid, Social Security, and Unemployment payments. Was it (READ ANSWERS)?


Less than 10 Thousand Dollars 01

10 to 30 Thousand Dollars 02

30 to 50 Thousand Dollars 03

50 to 70 Thousand Dollars 04

70 to 90 Thousand Dollars 05

90 to 110 Thousand Dollars 06

More than 110 Thousand Dollars 07

RF 98

DK 99


K5.

At that time, how many people were living in the household, including both adults and children?


# OF PEOPLE

RF 98

DK 99






A. How many of these were children under the age of 18?


# OF CHILDREN

RF 98

DK 99





K6.

I’ve asked about some things we think might be associated with development. Is there anything, including some of the factors we’ve already talked about that you think might cause autism or other developmental problems?


YES 01

NO (SKIP TO K8) 02

RF (SKIP TO K8) 98

DK (SKIP TO K8) 99





K7.

Can you tell me about those factors?




VERBATIM:








K8.

Why did you decide to be in this study?


VERBATIM:









K9.

That completes this interview. In case we need to get in touch with you in the future for this study, would you be willing to give us the name, address, and phone number of someone who should always know where you are? This information will be kept separate from your questionnaire. It will be locked except when needed by the research team, and will be destroyed when the study is finished. RECORD CONTACT INFO IN CIS.






IF CIS NOT AVAILABLE:


NAME OF CONTACT:

PREFIX: Ms. Mrs. Mr. Dr.

First Name: Last Name:

Street/Apartment:

City/State:

Home Phone: Work Phone:

Relationship:







In closing, we would like to sincerely thank you for your time and effort and your contribution to this important study. Your answers to these questions will help us greatly in our efforts to better understand the causes of autism and other developmental problems. Thank you.






TIME ENDED :

RECORD IN MILITARY TIME.




NOTE: IF DEMOGRAPHICS RECORDED IN INTERVIEW, ENTER NOW IN CIS.
















BLANK PAGE FOR END OF SECTION





SECTION L: INTERVIEWER STATUS


NOTE: ANSWER QUESTIONS IN SECTIONS L AND M AFTER EACH SESSION OF INTERVIEWING EVEN IF INTERVIEW WAS NOT COMPLETE.






L1.

L2.

L3.

L4.


Interviewer ID

Was the interview a phone or in-person interview?

Status of the interview:

Session date:


MM DD YYYY

SESSION #1

PHONE 01

IN-PERSON 02

Paused, not scheduled 03

Paused, scheduled 04

Finished, needs checking 05

Submitted, incomplete 08

Submitted, complete 09

- -

SESSION #2

PHONE 01

IN-PERSON 02

Paused, not scheduled 03

Paused, scheduled 04

Finished, needs checking 05

Submitted, incomplete 08

Submitted, complete 09

- -

SESSION #3

PHONE 01

IN-PERSON 02

Paused, not scheduled 03

Paused, scheduled 04

Finished, needs checking 05

Submitted, incomplete 08

Submitted, complete 09

- -

SESSION #4

PHONE 01

IN-PERSON 02

Paused, not scheduled 03

Paused, scheduled 04

Finished, needs checking 05

Submitted, incomplete 08

Submitted, complete 09

- -



SECTION M: INTERVIEWER REMARKS


NOTE: ANSWER QUESTIONS IN SECTIONS L AND M AFTER EACH SESSION OF INTERVIEWING EVEN IF INTERVIEW WAS NOT COMPLETE.






CODES FOR M2:



Did not know enough information regarding the topic 01

Did not want to be more specific 02

Sounded bored or uninterested 03

Sounded upset, depressed, or angry 04

Had poor hearing or speech 05

Sounded confused or distracted by frequent interruptions 06

Sounded inhibited by others around him or her 07

Sounded embarrassed by the subject matter 08

Sounded emotionally unstable 09

Sounded physically ill 10

Not comfortable with English language 11

Doesn’t have the time 12

Felt the interview was too long 13

Did not comprehend the questions 14

Other (SPECIFY IN GRID) 90







M1.

M2.

M3.


The overall quality of the interview in this session was:

The main reason for questionable or unsatisfactory quality of information was because the respondent:

Was the majority of the interview done today in English or in Spanish?

SESSION #1

High quality
(SKIP TO M3) 01

Generally reliable
(SKIP TO M3) 02

Questionable 03

Unsatisfactory 04



SPECIFY:

English 01

Spanish 02

Half English/half Spanish 03

SESSION #2

High quality
(SKIP TO M3) 01

Generally reliable
(SKIP TO M3) 02

Questionable 03

Unsatisfactory 04



SPECIFY:

English 01

Spanish 02

Half English/half Spanish 03

SESSION #3

High quality
(SKIP TO M3) 01

Generally reliable
(SKIP TO M3) 02

Questionable 03

Unsatisfactory 04



SPECIFY:

English 01

Spanish 02

Half English/half Spanish 03

SESSION #4

High quality
(SKIP TO M3) 01

Generally reliable
(SKIP TO M3) 02

Questionable 03

Unsatisfactory 04



SPECIFY:

English 01

Spanish 02

Half English/half Spanish 03


M4.

Additional comments. Use this space for any other comments you have which may affect the interpretation of this respondent’s answers.







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