Appendix
A A.1.1.a–
Visit Type: Enumeration
Target: Adult Household Member
T 36 Week Phone Call
T 36 Week Phone Call
FZ001. I’ll begin by asking about how your pregnancy is progressing. We have your due date recorded as {DUE DATE}. Is this still accurate?
YES 1 (FZ010)
NO, DATE IS DIFFERENT 2 (FZ006)
NO, PREGNANCY LOST 3 (FZ007)
NO, BABY ALREADY BORN 4
REFUSED 9--97 (FZ010)
DON’T KNOW 9--98 (FZ010)
FZ002. When was your baby born?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97
DON’T KNOW 9--98
FZ003. Sometimes babies who are born early need to spend extra time in the hospital before they can come home. Is your baby in the hospital or is your baby home now?
BABY IS AT HOSPITAL 1
BABY IS AT HOME 2 (FZ046)
OTHER (SPECIFY): 6 (FZ046)
REFUSED 9--97 (FZ046)
DON’T KNOW 9--98 (FZ046)
FZ004. At which hospital is your baby staying right now?
__________________________________________
HOSPITAL NAME
REFUSED 9--97 (FZ046)
DON’T KNOW 9--98 (FZ046)
FZ005. What is the address of the hospital?
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___| |___|___|___|___|___| (FZ046)
STATE ZIP CODE
REFUSED 9--97 (FZ046)
DON’T KNOW 9--98 (FZ046)
FZ006. What is your new due date?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97 (FZ010)
DON’T KNOW 9--98 (FZ010)
FZ007. I’m so sorry for your loss. I realize it may be difficult for you to talk about this, but it’s important for us to know when {you lost the baby. Can you please tell me the date when it happened/your baby was born. What was the date}?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97
DON’T KNOW 9--98
FZ008. Information about your pregnancy loss may help other women in the future. Would it be alright if we sent you some information on how you can allow the study to request a copy of the medical record for your loss?
YES 1
NO 2
FZ009. DID RESPONDENT REQUEST ADDITIONAL INFORMATION ON COPING WITH PREGNANCY LOSS?
YES 1 (FZ045)
NO 2 (FZ045)
FZ010. Do you plan on having a C-section to deliver your baby?
YES 1
NO 2 (BOX FZ01)
REFUSED 9--97 (BOX FZ01)
DON’T KNOW 9--98 (BOX FZ01)
FZ011. Have you scheduled a date to have the C-section?
YES 1
NO 2 (BOX FZ01)
REFUSED 9--97 (BOX FZ01)
DON’T KNOW 9--98 (BOX FZ01)
FZ012. What is that date?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97
DON’T KNOW 9--98
FZ013. QUESTION DELETED
FZ014. QUESTION DELETED
FZ015. QUESTION DELETED
BOX FZ02
CHECK ITEM:
|
FZ016. Are you using the Medical Care Log? This is the booklet that you or your doctor uses to record information about your doctors visits.
YES 1 (BOX FZ03)
NO 2
REFUSED 9--97 (BOX FZ03)
DON’T KNOW 9--98 (BOX FZ03)
FZ017. Is that because…
You haven’t had a medical visit since our last interview, 1
You’ve misplaced the log, or 2
You’ve forgotten to bring it to your medical visits? 3
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
BOX FZ03
CHECK ITEM:
|
FZ018. We’ll get another Medical Care Log in the mail to you today.
FZ019. This information is very important to the study. Please keep the log in a safe place {and remember to bring the log with you to any medical visit}.
FZ020. I am now going to ask some questions about visits to a doctor or other health care provider. It would be helpful if you referred to the Medical Care Log that you received as part of this study or to any other personal record or calendar that you keep that would help you to remember the dates of these visits. {I’ll be asking you to put a check mark in the box next to each visit once you’ve finished telling me about it.} If you have this information available, please go and get it now.
FZ021. Not including any overnight hospital stays, have you seen a doctor or other heath care provider since {MONTH}? Please include routine pregnancy checkups, sonograms or ultrasounds and other tests, as well as any other visits to a doctor or other health care provider because you were sick or injured, or for any other reason. (These would be the visits you noted in the yellow part of your Medical Care Log.)
YES 1
NO 2 (FZ036)
REFUSED 9--97 (FZ036)
DON’T KNOW 9--98 (FZ036)
BEGIN LOOP FZ01
LOOP:
|
FZ022. What was the date of {your/the next} most recent visit or checkup?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97
DON’T KNOW 9--98
FZ023. What kind of place did you go to? Was it a:
Doctor’s office, clinic, or health center 1
Hospital emergency room 2
Urgent care center, or 3
Some other place? (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
FZ024. What was the main reason for the visit? Was it for:
Routine pregnancy care, 1
Illness or injury, or 2 (FZ031)
Some other reason? (SPECIFY): 6 (FZ031)
REFUSED 9--97 (FZ031)
DON’T KNOW 9--98 (FZ031)
FZ024a. What type of provider did you see? Was it an:
Obstetrician/Gynecologist, 1
Family physician, 2
Nurse/Midwife, or 3
Another type of provider? (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
FZ025. At this visit, was your weight measured?
YES 1
NO 2 (FZ027)
REFUSED 9--97 (FZ027)
DON’T KNOW 9--98 (FZ027)
FZ026. At this visit, what was your weight?
|___|___|___|.|___|
WEIGHT
POUNDS 1
KILOGRAMS 2
REFUSED 9--97
DON’T KNOW 9--98
FZ027. At this visit, was your blood pressure measured?
YES 1
NO 2 (FZ030)
REFUSED 9--97 (FZ030)
DON’T KNOW 9--98 (FZ030)
FZ028. At this visit, what was your blood pressure?
INTERVIEWER INSTRUCTION:
BOTH SYSTOLIC AND DIASTOLIC MUST BE ENTERED. IF ONE OR BOTH ARE UNKNOWN, SELECT DK.
|___|___|___|
SYSTOLIC BLOOD PRESSURE
|___|___|___|
DIASTOLIC BLOOD PRESSURE
REFUSED 9--97
DON’T KNOW 9--98
BOX FZ05
CHECK ITEM:
|
FZ029. Do you remember if it was:
Normal, 1
High, or 2
Low? 3
REFUSED 9--97
DON’T KNOW 9--98
FZ030. At this visit, were any of the following procedures performed?
YES NO RF DK
a. Ultrasound? 1 2 9--97 9--98
b. Amniocentesis? 1 2 9--97 9--98
c. Chorionic Villi Sampling or CVS? 1 2 9--97 9--98
d. Other test or procedure? (SPECIFY): 1 2 9--97 9--98
BOX FZ06
CHECK ITEM:
|
FZ031. Did the doctor or other health care provider give you any diagnosis at this visit?
YES 1 (FZ032a)
NO 2 (FZ033)
REFUSED 9--97 (FZ033)
DON’T KNOW 9--98 (FZ033)
FZ032. At this visit, did the doctor or other health care provider tell you that you have any of the following conditions?
YES NO RF DK
a. Diabetes? 1 2 9--97 9--98
b. High blood pressure? 1 2 9--97 9--98
c. Protein in your urine? 1 2 9--97 9--98
d. Preeclampsia or toxemia? 1 2 9--97 9--98
e. Early or premature labor? 1 2 9--97 9--98
f. Anemia? 1 2 9--97 9--98
g. Severe nausea or hyperemisis? 1 2 9--97 9--98
h. Bladder or kidney Infection 1 2 9--97 9--98
i. Rh disease or isoimmunization? 1 2 9--97 9--98
j. Group B strep? 1 2 9--97 9--98
k. Herpes? 1 2 9--97 9--98
l. Bacterial vaginosis? 1 2 9--97 9--98
m. Pelvic inflammatory disease (PID), or infection in your tubes? 1 2 9--97 9--98
n. Other sexually transmitted disease or infection, such as chlamydia,
syphilis, or gonorrhea? 1 2 9--97 9--98
o. Any other serious condition? (SPECIFY): 1 2 9--97 9--98
FZ032a. What was the diagnosis?
SELECT ALL THAT APPLY.
COLD OR UPPER RESPIRATORY INFECTION 1
BLADDER OR KIDNEY INFECTION 2
FEVER 3
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
FZ033. Were you given any vaccinations at this visit? Vaccinations are usually injections or shots that strengthen people’s immune systems so that their bodies can fight off serious infectious diseases. Do not include allergy shots or Rhogam injections.
YES 1
NO 2 (FZ035)
REFUSED 9--97 (FZ035)
DON’T KNOW 9--98 (FZ035)
FZ034. What type of vaccination did you receive?
SELECT ALL THAT APPLY.
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT ANSWERS “TETANUS”, PROBE WHETHER SHE RECEIVED TETANUS/DIPHTHERIA (Td), or TETANUS, DIPHTHERIA AND PERTUSSIS (Tdap). IF SHE IS NOT SURE, SELECT “TETANUS/DIPHTHERIA (Td)”.
IF THE RESPONDENT ANSWERS “HEPATITIS”, PROBE TO FIND OUT WHETHER IT WAS FOR HEPATITIS A OR HEPATITIS B.
FLU/INFLUENZA 01
HEPATITIS B 02
HEPATITIS A 03
TETANUS/DIPHTHERIA (Td) 04
TETANUS, DIPHTHERIA AND PERTUSSIS (Tdap) 05
MENINGOCOCCAL 06
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9—98
FZ035. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Medical Care Log.
Have you had any other visits to a doctor or other health care provider since {MONTH}?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
END LOOP FZ01
LOOP:
|
FZ036. Since {MONTH} have you spent at least one night in the hospital?
YES 1
NO 2 (FZ044)
REFUSED 9--97 (FZ044)
DON’T KNOW 9--98 (FZ044)
BEGIN LOOP FZ02
LOOP:
|
FZ037. What was the admission date of your {next} most recent hospital stay?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97
DON’T KNOW 9--98
FZ038. How many nights did you stay in the hospital during this hospital stay?
|___|___|___|
NUMBER OF NIGHTS
REFUSED 9--97
DON’T KNOW 9--98
FZ039. Did a doctor or other health care provider give you a diagnosis during this hospital stay?
YES 1
NO 2 (FZ041)
REFUSED 9--97 (FZ041)
DON’T KNOW 9--98 (FZ041)
FZ040. What was the diagnosis?
SELECT ALL THAT APPLY.
DEHYDRATION 01
PRETERM LABOR 02
HYPEREMISIS 03
PREECLAMPISA 04
RUPTURE OF MEMBRANES 05
KIDNEY DISORDER 06
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
FZ041. Did you receive any treatments during this hospital stay? Please include any vaccinations you may have received.
YES 1
NO 2 (FZ043)
REFUSED 9--97 (FZ043)
DON’T KNOW 9--98 (FZ043)
FZ042. What treatments did you receive?
_____________________________________________________
TREATMENTS
REFUSED 9--97
DON’T KNOW 9--98
FZ043. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Medical Care Log.
Have you had any other hospitalizations since {MONTH}?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
END LOOP FZ02
LOOP:
|
FZ044. These are all the questions I have at this time. {We’ll send another Medical Care Log in the mail right away.} {Please remember to bring the Medical Care Log with you to any doctor’s visits you may have until your baby is born.}
As was previously mentioned, it is important for the study center to know when you go into labor. INSERT VC/SC SPECIFIC PROCEDURES HERE. Thank you for your time.
BOX FZ06
CHECK ITEM:
|
FZ045. Again, I’d like to say how sorry I am for your loss. {We’ll send the information packet you requested as soon as possible.} Please accept our best wishes for a quick recovery. {We’ll call you again in a few months to see how you’re doing.} Thank you for your time.
BOX FZ07
CHECK ITEM:
|
FZ046. It is important to the study that we collect information soon after birth for all babies. We know that the time after the birth of a new baby can be very busy. [NAME OF VC COORDINATOR] who has spoken with you before will be calling you shortly to set up an appointment to get some information on how your baby is doing. Thanks so much for your time and best wishes as your family adjusts to its new arrival.
Revised 7/2/08
| File Type | application/msword |
| File Title | Pregnancy Phone Follow-up – T 36 Weeks |
| File Modified | 2008-09-15 |
| File Created | 2008-09-15 |