Appendix
A A.1.2a -
Version 1/20/08 Visit Type: P1
Target: Mother
Section: IN; #
P1 Visit: Interview Introduction
IN001. Thank you for agreeing to participate in this study. We are about to begin the interview portion of today’s home visit, which will take about 30 minutes to complete. Your answers are important to us. There are no right or wrong answers, just those that help us to understand your situation. There are questions about where you live, your lifestyle routines, and your health during this interview and you can always refuse to answer any question or group of questions. If you need a bathroom break at any time please let me know so that I can give you the materials to collect the samples that are needed today.
Before we start, can you get the medicines and any pesticide products that you were asked to gather for this appointment?
IN002 AFTER RESPONDENT GATHERS MATERIALS, OR INDICATES THAT SHE DOESN’T HAVE ANY TO GATHER, SAY:
Are you ready to begin?
YES 1
NO 2 (END interview)
P1 Visit: Household Composition and Demographics: Part 1
DE001. First, I’d like to get some information about the people who live here.
DE002. How many people, both children and adults, live in this household? Include any persons who usually stay here but are temporarily away on business, vacation, in the hospital, on full-time active military duty, or students living temporarily away from home. Do not include anyone who is in a nursing home or other institution. Including yourself, what is the total number of people who live here?
|___|___|
NUMBER
REFUSED 9--97
DON’T KNOW 9--98
BOX DE01
CHECK ITEM: IF DE002 = “1”, GO TO DE008. OTHERWISE, CONTINUE WITH DE003.
|
DE003. Now I’d like to ask some questions about each person in your household, starting with the oldest. Please list everyone who lives here, except yourself.
DE004. NAME
__________________ UNIQUE FIRST NAME
REFUSED 9--97 DON’T KNOW 9--98
|
DE005. AGE
|___|___|___| AGE
REFUSED 9--97 DON’T KNOW 9--98
|
DE006. GENDER
MALE 1 FEMALE 2 REFUSED 9--97 DON’T KNOW 9--98
|
DE007. RELATIONSHIP
SELF 00 SPOUSE 01 BIOLOGICAL SON/DAUGHTER 02 ADOPTED SON/DAUGHTER 03 STEPSON/STEPDAUGHTER 04 BROTHER/SISTER 05 FATHER/MOTHER 06 GRANDCHILD 07 PARENT-IN-LAW 08 SON-IN-LAW/DAUGHTER-IN-LAW 09 ROOMER, BOARDER 10 HOUSEMATE, ROOMMATE 11 UNMARRIED PARTNER 12 FOSTER CHILD 13 OTHER NONRELATIVE 14 OTHER RELATIVE 15
|
DE008. Now I’d like to ask about your marital status. What is your current marital status? Are you:
INTERVIEWER INSTRUCTION:
CONFIRM IF KNOWN.
Married, 01
Not married but living together with a partner of the opposite sex, 02
Not married but living together with a partner of the same sex, 03
Widowed, 04
Divorced, 05
Separated, or 06
Never been married? 07
REFUSED 9--97
DON’T KNOW 9--98
BEGIN LOOP DE01
|
DE009. {Do you/Does {NAME}} consider {yourself/(himself/herself)} to be Hispanic, or Latino/a?
INTERVIEWER INSTRUCTION:
IF ASKING ABOUT A FEMALE HOUSEHOLD MEMBER READ LATINA.
YES 1
NO 2 (DE011)
REFUSED 9--7 (DE011)
DON’T KNOW 9--8 (DE011)
DE010. Please give me the number of the group that represents {your/NAME’s} Hispanic origin or ancestry.
SHOW CARD DE2.
PUERTO RICAN 01
CUBAN/CUBAN AMERICAN 02
DOMINICAN (REPUBLIC) 03
MEXICAN 04
MEXICAN AMERICAN 05
CENTRAL OR SOUTH AMERICAN 06
OTHER 96
REFUSED 9--97
DON’T KNOW 9--98
DE011. What race {do/does} {you/NAME} consider {yourself/(himself/herself)} to be?
PROBE: Anything else?
SELECT ALL THAT APPLY.
White, 1
Black or African American, 2
Asian, 3
Native Hawaiian or Other Pacific Islander, 4
American Indian or Alaska Native, or 5
Some other race? (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
DE012. Please look at the card and tell me what is the highest degree or level of school that {you/NAME} {have/has} completed?
SHOW CARD DE3.
NO SCHOOL 01
ELEMENTARY
NURSERY SCHOOL TO 4TH GRADE 02
5TH–6TH GRADE 03
7TH–8TH GRADE 04
HIGH SCHOOL
9TH GRADE 05
10TH GRADE 06
11TH GRADE 07
12TH GRADE (NO DIPLOMA) 08
HIGH SCHOOL DIPLOMA 09
GED OR EQUIVALENT 10
COLLEGE
SOME COLLEGE CREDITS, BUT LESS THAN 1 YEAR 11
1 OR MORE YEARS OF COLLEGE, BUT NO DEGREE 12
ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR
VOCATIONAL PROGRAM 13
ASSOCIATE DEGREE: ACADEMIC PROGRAM 14
BACHELOR’S DEGREE (e.g., BA, BS) 15
GRADUATE
MASTER’S DEGREE (e.g., MA, MS, MSW, MEng, MBA) 16
PROFESSIONAL SCHOOL DEGREE (e.g., MD, DDS, DVM, JD) 17
DOCTORAL DEGREE (e.g., Ph.D., Ed.D.) 18
REFUSED 9--97
DON’T KNOW 9--98
END LOOP DE01
|
P1 Visit: Health Behaviors Part 1
HB001. The following questions are about your sleep habits during the past 7 days.
HB002. Thinking of the past 7 days, on a typical day, how much time did you sleep at night?
|___|___| |___|___|
HOURS MINUTES
Less than 4 hours, 1
4–5 hours, 2
6–7 hours, 3
8–9 hours, or 4
10 or more hours? 5
REFUSED 9--97
DON’T KNOW 9--98
HB003. During the past 7 days, on a typical day, how much additional time did you sleep during the day?
|___|___| |___|___|
HOURS MINUTES
Not at all, 1
Less than 1 hour, 2
1–2 hours, or 3
More than 2 hours? 4
REFUSED 9--97
DON’T KNOW 9--98
HB004. Next, I’m going to ask about the time you spent being physically active in the last 7 days.
Please answer each question even if you do not consider yourself to be an active person. Think about the activities you do at work, as part of your house or yard work, to get from place to place, and in your spare time for recreation, exercise or sport.
Now, think about all the vigorous activities that take hard physical effort that you did in the last 7 days. Vigorous activities make you breathe much harder than normal and may include heavy lifting, digging, aerobics, or fast bicycling. Think only about those activities that you did during the last 7 days for at least 10 minutes at a time.
HB005. During the last 7 days, on how many days did you do vigorous physical activities?
|___|
NUMBER OF DAYS
REFUSED 9--97 (HB008)
DON’T KNOW 9--98 (HB008)
BOX HB01
CHECK ITEM:
|
HB006. On average, how much time did you usually spend doing vigorous physical activities on each of those days?
PROBE: IF RESPONDENT GIVES AN ANSWER THAT IS LESS THAN 10 MINUTES: “Please think only of activities that you have done for at least 10 minutes at a time.”
|___|___| |___|___| (HB008)
HOURS MINUTES
REFUSED 9--97 (HB008)
DON’T KNOW 9--98
HB007. How much time in total did you spend over the last 7 days doing vigorous physical activities?
|___|___| |___|___|
HOURS MINUTES
REFUSED 9--97
DON’T KNOW 9--98
HB008. Now think about activities which take moderate physical effort that you did in the last 7 days. Moderate physical activities make you breathe somewhat harder than normal and may include carrying light loads, bicycling at a regular pace, or doubles tennis. Do not include walking. Again, think about only those physical activities that you did for at least 10 minutes at a time.
HB009. During the last 7 days, on how many days did you do moderate physical activities?
|___|
NUMBER OF DAYS
REFUSED 9--97 (HB012)
DON’T KNOW 9--98 (HB012)
BOX HB02
CHECK ITEM:
|
HB010. On average, how much time did you usually spend doing moderate physical activities on each of those days?
PROBE: IF RESPONDENT GIVES AN ANSWER THAT IS LESS THAN 10 MINUTES: “Please think only of activities that you have done for at least 10 minutes at a time.”
|___|___| |___|___| (HB012)
HOURS MINUTES
REFUSED 9--97 (HB012)
DON’T KNOW 9--98
HB011. What is the total amount of time you spent over the last 7 days doing moderate physical activities?
|___|___| |___|___|
HOURS MINUTES
REFUSED 9--97
DON’T KNOW 9--98
HB012. Now think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.
HB013. During the last 7 days, on how many days did you walk for at least 10 minutes at a time?
|___|
NUMBER OF DAYS PER WEEK
REFUSED 9--97 (HB016)
DON’T KNOW 9--98 (HB016)
BOX HB03
CHECK ITEM:
|
HB014. On average, how much time did you usually spend walking on each of those days?
PROBE: IF RESPONDENT GIVES AN ANSWER THAT IS LESS THAN 10 MINUTES: “Please think only of activities that you have done for at least 10 minutes at a time.”
|___|___| |___|___| (HB016)
HOURS MINUTES
REFUSED 9--97 (HB016)
DON’T KNOW 9--98
HB015. What is the total amount of time you spent walking over the last 7 days?
|___|___| |___|___|
HOURS MINUTES
REFUSED 9--97
DON’T KNOW 9--98
HB016. Overall, how would you say your activity level has changed since you found out you were pregnant? Has it…
Stayed the same as before you were pregnant, 1
Increased a lot, 2
Increased a little, 3
Decreased a little, or 4
Decreased a lot? 5
REFUSED 9--97
DON’T KNOW 9--98
HB017. Now I’d like to change topics and ask you some questions about drinking beverages with caffeine.
HB018. Currently, do you drink:
IF YES: On average, how many of these drinks do you have per day?
INTERVIEWER INSTRUCTION:
IF ANSWER IS “NO” WRITE IN “0” FOR HOW MANY PER DAY.
IF RESPONDENT DRINKS LESS THAN 1 DRINK PER DAY, WRITE IN “0” FOR HOW MANY PER DAY.
HOW
MANY
YES NO PER DAY RF DK
a. Caffeinated coffee? 1 2 |___|___| 9--97 9--98
b. Caffeinated tea? 1 2 |___|___| 9--97 9--98
c. Soda with caffeine (Coke, Pepsi, Dr. Pepper, Mountain Dew)? 1 2 |___|___| 9--97 9--98
d. Energy drinks with caffeine (Red Bull, Amp)? 1 2 |___|___| 9--97 9--98
P1 Visit: Use of Medicines, Supplements and Alternative Medicines
UM001. The next questions are about your use of prescription medications, over-the-counter medications, and dietary supplements.
UM002. In the past 30 days, have you used or taken medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. Please include prescription vitamins or minerals.
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
UM003. In the past 30 days, have you used or taken any over-the-counter or nonprescription medications, or any nonprescription vitamins, minerals, herbals, or other dietary supplements? This card lists some examples of different types of over-the-counter medications, vitamins, minerals, and dietary supplements.
SHOW CARD UM1.
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
BOX UM01
CHECK ITEM:
|
UM004. May I please see the containers for all the {prescriptions,} {and} {non-prescription medicines and supplements}, that you used or took in the past 30 days?
RESPONDENT HAS CONTAINERS 1
RESPONDENT DOES NOT HAVE CONTAINERS 2
BOX UM02
CHECK ITEM:
|
UM005. I will start with the prescription medications. {Please show me any you have taken in the past 30 days/Please tell me the names of the prescription medications and supplements that you have taken in the past 30 days}.
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER. ACTIVATE LOOKUP AND SELECT MEDICATIONS FROM LIST. IF A MEDICATION IS NOT ON LIST, ENTER THE FULL NAME (INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
PRODUCT ON PRESCRIPTION MEDICINE LIST 1
PRODUCT NOT ON LIST (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
BEGIN LOOP UM01
LOOP:
|
UM006. First let’s talk about {MEDICATION}.
UM007. PRODUCT LABEL SEEN?
YES 1
NO 2
UM008. RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK: How is the {MEDICATION} taken?
By mouth, 01
Inhaled either by mouth or nose, 02
Injected, 03
Applied to the skin, such as a patch or creams, or 04
Some other way? (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
UM009. Are you still taking {MEDICATION}?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
UM010. How often {do/did} you use or take {MEDICATION}?
|___|___|
ENTER NUMBER
ENTER UNIT
PER DAY 1
PER WEEK 2
PER MONTH 3
PER YEAR 4
AS NEEDED 9--95
REFUSED 9--97
DON’T KNOW 9--98
END LOOP UM01
LOOP:
|
BOX UM03
CHECK ITEM:
|
UM011. Now let’s talk about your use of over-the-counter medications and nonprescription vitamins, minerals, herbals, and other dietary supplements. {Please show me any you have taken in the past 30 days/Please tell me the names of the nonprescription medications and nonprescription vitamins, minerals, herbals, and supplements that you have taken in the past 30 days}
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER. ACTIVATE LOOKUP AND SELECT PRODUCT FROM LIST. IF PRODUCT NOT ON LIST, ENTER THE FULL NAME (INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
SHOW CARD UM1.
PRODUCT ON MEDICINE LIST 1
PRODUCT NOT ON LIST (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
BEGIN LOOP UM02
LOOP:
|
UM012. Let’s talk about {PRODUCT}.
UM013. WAS PRODUCT LABEL SEEN?
YES 1
NO 2
UM014. RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK: How is the {PRODUCT} taken?
By mouth, 01
Inhaled either by mouth or nose, 02
Injected, 03
Applied to the skin, such as a patch or creams, or 04
Some other way? (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
UM015. {In the past 30 days/Since you became pregnant}, how often have you taken {PRODUCT}:
Less than once a month, 01
Once a month, 02
2–3 times a month (but less than once a week), 03
1–2 times a week, 04
3–4 times a week, 05
5–6 times a week, or 06
Every day? 07
REFUSED 9--97
DON’T KNOW 9--98
UM016. Are you still taking {PRODUCT}?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
END LOOP UM02
LOOP:
|
P1 Visit: Pets and Pesticide Use
PP001. Now I’d like to ask about any pets you may have.
PP002. Are there any pets that spend any time inside your home?
YES 1
NO 2 (PP008)
REFUSED 9--97 (PP008)
DON’T KNOW 9--98 (PP008)
PP003. What kind of pets are these?
SELECT ALL THAT APPLY.
DOG 1
CAT 2
SMALL
MAMMAL (RABBIT, GERBIL, HAMSTER, GUINEA PIG,
FERRET, MOUSE) 3
BIRD 4
FISH OR REPTILE (TURTLE, SNAKE, LIZARD) 5
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
PP004. Are any products ever used on your pets to control fleas, ticks, or mites? This includes flea collars, flea and tick powders, shampoos, or other flea, tick, and mite control products. (This does not include pills given to your pet to control for fleas or other insects.)
YES 1
NO 2 (PP008)
REFUSED 9--97 (PP008)
DON’T KNOW 9--98 (PP008)
PP005. When were any of these last used on any of your pets?
Within the last month, 1
1–3 months ago, 2
4–6 months ago, or 3
More than 6 months ago? 4 (PP008)
REFUSED 9--97 (PP008)
DON’T KNOW 9--98 (PP008)
PP006. What are the names of the products used on your pets to control fleas, ticks, or mites? Please show me the products or containers if you have them.
_____________________________________________________
ENTER PRODUCT NAME FROM LIST
REFUSED 9--97
DON’T KNOW 9--98
PP007. Did you personally handle or apply any of these products to your pets?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
PP008. I would now like to ask about products that may have ever been used in your home or yard to control for ants, termites, cockroaches, bees, wasps, moths, or other insects during the past 6 months.
PP009. When were any pesticides last used inside or outside this residence to control for insects?
Within the last month, 1
1–3 months ago, 2
4–6 months ago, 3
More than 6 months ago, or 4 (EOS)
Never? 5 (EOS)
REFUSED 9--97 (EOS)
DON’T KNOW 9--98 (EOS)
PP010. In preparation for this interview, we asked that you gather together any of the pesticide cans or containers you may have used in the last 6 months. You may also have letters from building maintenance about pesticide application, or receipts from the exterminator that list which products were used. Please show me, or tell me the names of the products that have been used within the last 6 months, either indoors or outdoors, to treat for insects?
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT, LETTER, OR RECEIPT IS PROVIDED.
_____________________________________________________
PRODUCT NAME FROM LIST
_____________________________________________________
REGISTRATION NUMBER IF KNOWN
REFUSED 9--97 (EOS)
DON’T KNOW 9--98 (EOS)
BEGIN LOOP PP01
LOOP:
|
PP011. How was the {PRODUCT} applied?
SELECT ALL THAT APPLY.
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT IS PROVIDED.
SPRAY 01
BOMB 02
POWDER 03
STRIP 04
MOTH BALLS 05
FOAM 06
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
PP012. Which of the following areas of your home were treated with {PRODUCT}? Was it…
YES NO RF DK
a. The
common living area, that is the room other than bedroom or
kitchen
where you spend most of your time? 1 2 9--97 9--98
b. The kitchen? 1 2 9--97 9--98
c. Your bedroom? 1 2 9--97 9--98
d. The basement? 1 2 9--97 9--98
e. Any other rooms? 1 2 9--97 9--98
f. Outdoors, around the walls of your house or building? 1 2 9--97 9--98
g. Outdoors, in the garden or yard? 1 2 9--97 9--98
h. Common
areas inside building but outside of your home or
apartment
(public foyer or hallway, etc.)? 1 2 9--97 9--98
PP013. Who applied the {PRODUCT}? Was it….
You, 1
A professional exterminator, or 2
Someone else? 3
REFUSED 9--97
DON’T KNOW 9--98
PP014. How often was the {PRODUCT} used in the past 6 months?
More than once a month, or 1
Once a month or less? 2
REFUSED 9--97
DON’T KNOW 9--98
BOX PP03
CHECK ITEM:
|
PP015. When you applied the {PRODUCT}, did you usually wear any protective items such as gloves or a mask?
YES 1
NO 2 (EL_PP01)
REFUSED 9--97 (EL_PP01)
DON’T KNOW 9--98 (EL_PP01)
PP016. Which protective items did you wear?
SELECT ALL THAT APPLY.
GLOVES 1
MASK 2
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
END LOOP PP01
LOOP:
|
P1 Visit: Occupational/Hobby Exposures
OH001. Now I would like to ask some questions about any schoolwork, jobs, volunteer work, and hobbies that you have done recently. Please only include activities that you do (or have done) for 4 hours a week or longer.
OH002. Are you currently a full- or part-time student? This includes vocational or technical schooling that may not be done in a classroom.
PROBE: Do you go full-time or part-time?
NO, NOT A STUDENT 1 (OH007)
YES, FULL-TIME STUDENT 2
YES, PART-TIME STUDENT 3
REFUSED 9--97 (OH007)
DON’T KNOW 9--98 (OH007)
OH003. What type of school are you currently attending?
HIGH SCHOOL 1
TECHNICAL SCHOOL 2
COLLEGE OR UNIVERSITY 3
GRADUATE SCHOOL 4
PROFESSIONAL SCHOOL (E.G., MEDICAL, LAW, DENTAL) 5
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
OH004. Please refer to this card and tell me, what best describes the place where you typically go to school?
SHOW CARD OH1.
SELECT ALL THAT APPLY.
CLASSROOM 01
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S HOME 02
LABORATORY 03
GARAGE OR SHOP 04
MOTOR VEHICLE 05
SOME OTHER LOCATION (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
OH005. What is the address where you actually attend school most often?
HOME 1 (OH007)
VARIES (CONSTRUCTION, LANDSCAPING) 2 (OH007)
HAVE EXACT ADDRESS 3
OTHER (SPECIFY): 6 (OH007)
REFUSED 9--97 (OH007)
DON’T KNOW 9--98 (OH007)
OH006. (Please tell me the address where you actually attend school most often.)
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___| |___|___|___|___|___|
STATE ZIP CODE
REFUSED 9--97
DON’T KNOW 9--98
OH007. Now I would like to ask you about the jobs you have had recently. {In the past 3 months/Since you became pregnant}:
NUMBER RF DK
a. How many full-time jobs have you had? |___|___| 9--97 9--98
b. How many part-time jobs have you had? |___|___| 9--97 9--98
c. How
many volunteer jobs have you had (fire department,
humane
society, etc.)? |___|___| 9--97 9--98
BOX OH01
CHECK ITEM:
|
BOX OH02
CHECK ITEM:
|
BEGIN LOOP OH01
LOOP:
|
BOX OH03
CHECK ITEM:
|
OH008. {Now I’d like to ask some questions about each one of your jobs, starting with the job where you work the most hours/Now think about the job where you work the next greatest number of hours}.
OH009. Are you currently employed at this job?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
OH010. For this job, what {is/was} your job title or occupation?
_____________________________________________________
JOB TITLE
REFUSED 9--97
DON’T KNOW 9--98
OH011. For this job, who {is/was} your employer?
_____________________________________________________
EMPLOYER
REFUSED 9--97
DON’T KNOW 9--98
OH012. What types of activities {do/did} you do most often at this job? For example, teach classes, work on the computer, keep account books, file, photocopy, answer phone, wait tables, help customers, do lab work, or carpentry?
PROBE: Anything else?
_____________________________________________________
ACTIVITY
REFUSED 9--97
DON’T KNOW 9--98
OH013. In what kind of business or industry {is/was} this job? That is, what does this company make or do?
_____________________________________________________
INDUSTRY
REFUSED 9--97
DON’T KNOW 9--98
OH014. On average, how many hours a week {do/did} you usually work at this job?
|___|___|___|
NUMBER OF HOURS
REFUSED 9--97
DON’T KNOW 9--98
OH015. {Does/Did} this include working a shift (starts/started) after 2 pm?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
OH016. {Do/Did} you rotate among different shifts for this job?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
OH017. Please look at this card and tell me, what best describes the place where you typically {work/worked} for this job?
PROBE: Is this indoors or outdoors?
SHOW CARD OH2.
SELECT ALL THAT APPLY.
OFFICE AREA 01
STORE 02
CLASSROOM 03
HOTEL OR MOTEL 04
RESTAURANT 05
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S HOME 06
HEALTHCARE FACILITY OR HOSPITAL 07
LABORATORY 08
FACTORY, PLANT, OR PRODUCTION AREA 09
WAREHOUSE 10
GARAGE OR SHOP 11
SALON 12
LOADING DOCK 13
CONSTRUCTION SITE 14
GROUNDS, YARD, OR GARDEN 15
MOTOR VEHICLE 16
SOME OTHER LOCATION (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
OH018. What is the address where you actually {work/worked} at this job?
HOME 1 (EL_OH01)
VARIES (CONSTRUCTION, LANDSCAPING) 2 (EL_OH01)
HAVE EXACT ADDRESS 3
OTHER (SPECIFY): 6 (EL_OH01)
REFUSED 9--97 (EL_OH01)
DON’T KNOW 9--98 (EL_OH01)
OH019. Please tell me the address where you actually {work/worked} at this job.
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___| |___|___|___|___|___|
STATE ZIP CODE
REFUSED 9--97
DON’T KNOW 9--98
END LOOP OH01
LOOP:
|
OH020. Now I want to ask about any cleaning products, chemicals, pesticides, radiation, or bacteria or viruses that you may have worked around or used during the past 3 months at any job, school, or hobby when answering these questions. Please consider all jobs, schools, and hobbies that you do for at least 4 hours per week. Do not include regular household use.
BEGIN LOOP OH02
LOOP:
|
OH021. (In any {full or part-time job,} {volunteer job,} {school,} {or} hobby have you used or worked around):
any {cleaning products, such as bleach, ammonia, or detergents/chemicals, such as paints, fuels, solvents, oils, glues, or hair or nail products/pesticides that you’ve mixed or applied/dusts, including wood or mining dust/fumes or gases, such as from anesthetic gases, ethylene oxide, welding or asphalt fumes, or engine exhaust/radiation, including x-rays, fluoroscopy, or radioisotopes/bacteria or viruses, such as those used in a laboratory setting}?
(Again, do not include regular household use.)
YES 1
NO 2 (EL_OH02)
REFUSED 9--97 (EL_OH02)
DON’T KNOW 9--98 (EL_OH02)
DISPLAY INSTRUCTIONS:
IF FIRST CYCLE, DISPLAY “{cleaning products, such as bleach, ammonia, or detergents}.”
IF SECOND CYCLE, DISPLAY “{chemicals, such as paints, fuels, solvents, oils, glues, or hair or nail products}.”
IF THIRD CYCLE, DISPLAY “{pesticides that you’ve mixed or applied}.”
IF FOURTH CYCLE, DISPLAY “{dusts, including wood or mining dust}.”
IF FIFTH CYCLE, DISPLAY “{fumes or gases, such as from anesthetic gases, ethylene oxide, welding or asphalt fumes, or engine exhaust}.”
IF SIXTH CYCLE, DISPLAY “{radiation, including x-rays, fluoroscopy, or radioisotopes}.”
IF SEVENTH CYCLE, DISPLAY “{bacteria or viruses, such as those used in a laboratory setting}.”
OH022. Please tell me the name of (or describe) the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/bacteria or viruses}?
_____________________________________________________
NAME OR DESCRIPTION OF EXPOSURE
REFUSED 9--97
DON’T KNOW 9--98
OH023. Do
you handle or work directly with the {cleaning
products/chemicals/pesticides/dusts/fumes or
gases/radiation/
bacteria or viruses} or do you just work around
it?
DON’T WORK DIRECTLY WITH THE MATERIAL 1
HANDLE DIRECTLY (POUR, TOUCH, ETC.) 2
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
OH024. Now thinking of the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/bacteria or viruses} that you just mentioned….
OH025. During the past 3 months, how often did you wear or use personal protective equipment to protect yourself from the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/bacteria or viruses}? By personal protective equipment, I mean things like gloves, dust masks, goggles, aprons, lab coats, or other protective clothing. Would you say you always, often, rarely, or never use personal protective equipment?
ALWAYS 1
OFTEN 2
RARELY 3
NEVER 4 (OH028)
REFUSED 9--97 (OH028)
DON’T KNOW 9--98 (OH028)
OH026. Please look at this card and tell me which types of protective clothing or equipment have you worn?
PROBE: Any other protective clothing or equipment?
SHOW CARD OH3.
SELECT ALL THAT APPLY.
GLOVES 01
OVERALLS 02
OVERCOAT (E.G., LAB COAT, SMOCK, APRON) 03
DUST MASK 04
RESPIRATOR 05
GOGGLES/SAFETY GLASSES/FACE SHIELD 06
WORK BOOTS/SHOES 09
LEAD APRON 08
SOMETHING ELSE (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
OH027. What type of respirator was it?
A
half-mask chemical cartridge respirator, which is silicone or rubber
and covers your mouth and nose, 1
A
full-mask chemical cartridge respirator, which is silicone or rubber
and covers your eyes, nose, and mouth, 2
An air-supplied or SCBA respirator, or 3
Some other kind of respirator? (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
OH028. Is there any kind of a ventilation system to remove exhaust, dust, smoke or fumes from the area? By ventilation system we mean purposely opening windows or doors, using a fume hood, or other ventilation system.
YES 1
NO 2 (EL_OH02)
REFUSED 9--97 (EL_OH02)
DON’T KNOW 9--98 (EL_OH02)
OH029. What ventilation systems are present to remove exhaust, dust, smoke or fumes from the area? Is there….
SELECT ALL THAT APPLY.
General ventilation, meaning open doors or windows, fans, etc. 01
A regular HVAC system for building and room heating and cooling, 02
A fume hood, lab hood, or other partially enclosed equipment, 03
A glove box or other totally enclosed equipment, 04
A
portable exhaust hose or tube, such as those used for welding or to
attach to vehicle tailpipe, or 05
Some other type of ventilation system? (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
END LOOP OH02
LOOP:
|
P1 Visit: Household Composition and Demographics: Part 2
DM001. These next questions are about your background and cultural heritage.
DM002. Were you born in the United States?
YES 1 (DM005)
NO 2
REFUSED 9--97 (DM005)
DON’T KNOW 9--98 (DM005)
DM003. In what country were you born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED 9--97
DON’T KNOW 9--98
DM004. About how long have you lived in the United States?
INTERVIEWER INSTRUCTION:
IF LESS THAN ONE YEAR, ENTER ”00”.
|___|___|
YEARS
REFUSED 9--97
DON’T KNOW 9--98
DM005. Was your mother born in the United States?
YES 1 (DM007)
NO 2
REFUSED 9--97 (DM007)
DON’T KNOW 9--98 (DM007)
DM006. In what country was your mother born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED 9--97
DON’T KNOW 9--98
DM007. Was your father born in the United States?
YES 1 (DM009)
NO 2
REFUSED 9--97 (DM009)
DON’T KNOW 9--98 (DM009)
DM008. In what country was your father born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED 9--97
DON’T KNOW 9--98
DM009. These next questions are about the food eaten in your household in the last 12 months, and whether you were able to afford the food you need.
DM010. Which of these statements best describes the food eaten in your household in the last 12 months:
Enough of the kinds of food we want to eat, 1 (DM012)
Enough, but not always the kinds of food we want, 2 (DM012)
Sometimes not enough food to eat, or 3
Often not enough food to eat? 4
REFUSED 9--97 (DM012)
DON’T KNOW 9--98 (DM012)
DM011. Here are some reasons why people don’t always have enough to eat. For each one, please tell me if this is a reason why you don’t always have enough to eat.
YES NO RF DK
a. Not enough money for food? 1 2 9--97 9--98
b. Not enough time for shopping or cooking? 1 2 9--97 9--98
c. Too hard to get to the store? 1 2 9--97 9--98
d. On a diet? 1 2 9--97 9--98
e. No working stove available? 1 2 9--97 9--98
f. Not able to cook or eat because of health problems? 1 2 9--97 9--98
DM012. Now I’m going to switch the subject and ask about health insurance.
DM013. Do you currently have insurance through a current or former employer or union (of yourself or another family member)?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM014. (Do you currently have:)
Insurance purchased directly from an insurance company (by yourself or another family member)?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM015. (Do you currently have:)
Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM016. (Do you currently have:)
TRICARE, VA, or other military health care?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM017. (Do you currently have:)
Indian Health Service?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM018. (Do you currently have:)
Medicare, for people 65 and older, or people with certain disabilities?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM019. (Do you currently have:)
Any other type of health insurance or health coverage plan?
YES (SPECIFY): 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM020. Lastly, I’d like to find out how you see yourself in relation to other people in the United States.
DM021. Please look at this card. Think of this ladder as representing where people stand in the United States. At the top of the ladder are the people who are the best off—those who have the most money, the most education and the most respected jobs. At the bottom are the people who are the worst off—who have the least money, least education, and the least respected jobs or no job.
Where would you place yourself on this ladder?
Please point to the rung where you think you stand at this time in your life, relative to other people in the United States.
SHOW CARD DM1.
RUNG A 01
RUNG B 02
RUNG C 03
RUNG D 04
RUNG E 05
RUNG F 06
RUNG G 07
RUNG H 08
RUNG I 09
RUNG J 10
REFUSED 9--97
DON’T KNOW 9--98
P1 Mom Interview: Tracing Information
TR001. Finally, I need to ask you a few questions so that staff from the National Children’s Study may contact you again.
TR002. Sometimes if people move or change their telephone number, we have difficulty reaching them. Could I have the names and telephone numbers of 1 or 2 friends or relatives not currently living with you who should know where you could be reached in case we have trouble contacting you?
YES 1
NO 2 (TR011)
REFUSED 9--97 (TR011)
DON’T KNOW 9--98 (TR011)
TR003. I’d like to collect some basic contact information on this person/these people. What is the first person’s name?
________________ ________________
FIRST NAME LAST NAME
REFUSED 9--97 (TR011)
DON’T KNOW 9--98 (TR011)
TR004. What is his/her relationship to you?
MOTHER/FATHER 01
BROTHER/SISTER 02
AUNT/UNCLE 03
GRANDPARENT 04
NEIGHBOR 05
FRIEND 06
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
TR005. What is his/her address?
_____________________________________________________
STREET
_____________________________________________________
CITY
|___|___| |___|___|___|___|___|
STATE ZIP CODE
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED 9--97 (TR007)
DON’T KNOW 9--98
TR006. What is his/her telephone number?
I__I__I__I – I__I__I__I – I__I__I__I__I
PHONE NUMBER
NONE 9--91
REFUSED 9--97
DON’T KNOW 9--98
TR007. Now I’d like to collect information on a second contact. What is this person’s name?
______________ __________________
FIRST NAME LAST NAME
NO SECOND CONTACT PROVIDED 9--91 (TR011)
REFUSED 9--97 (TR011)
DON’T KNOW 9--98 (TR011)
TR008. What is his/her relationship to you?
MOTHER/FATHER 01
BROTHER/SISTER 02
AUNT/UNCLE 03
GRANDPARENT 04
NEIGHBOR 05
FRIEND 06
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
TR009. What is his/her address?
_____________________________________________________
STREET
_____________________________________________________
CITY
|___|___| |___|___|___|___|___|
STATE ZIP CODE
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED 9--97 (TR011)
DON’T KNOW 9--98
TR010. What is his/her telephone number?
I__I__I__I – I__I__I__I – I__I__I__I__I
PHONE NUMBER
NONE 9--91
REFUSED 9--97
DON’T KNOW 9--98
TR011. Finally, could you please tell me your Social Security Number or Individual Taxpayer Identification Number? The National Children’s Study may use your Social Security Number to conduct health-related research by linking your survey data with vital statistics and other health records. We also may use it if we need to locate you or your family in the future. Except for these purposes, the Study will not release your Social Security Number to anyone, including any government agency. Providing this information is voluntary. Whether or not you give us this number will have no effect on any benefits you might receive. The National Children’s Study is authorized by the Children’s Health Act of 2000 and the Public Health Service Act. (The Public Health Service Act authority is found under Section 448 (42USC 285g).
|___|___|___| |___|___| |___|___|___|___|
REFUSED 9--97
DON’T KNOW 9--98
TR012. Thank you for answering these questions. This completes the interview portion of the visit.
| File Type | application/msword |
| File Title | T1 Mom Visit: Household Composition and Demographics: Part 1 |
| Author | Lori Houck |
| Last Modified By | Sniffin_T |
| File Modified | 2008-01-24 |
| File Created | 2008-01-22 |