Form A.1.1.b Survey

Pilot Study for the National Children's Study (NICHD)

A.1.1.b Pregnancy Screener

Eligibility Screening

OMB: 0925-0593

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0925-0593 can be found here:

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Appendix A A.1.1.a–0

Visit Type: Enumeration

Target: Adult Household Member

Pregnancy Screener

CONSENT FOR PREGNANCY SCREENER

(FOR ELIGIBLE FEMALES WHO WERE NOT ENUMERATION RESPONDENT)

1. INTRODUCTION: Hello, I’m (DATA COLLECTOR’S NAME) from [LOCAL STUDY AFFILIATE]. [SHOW ID BADGE.] We’re conducting an important research study called the National Children’s Study with the National Institutes of Health. You may have gotten a letter and brochure from us about it [HAND LETTER AND BROCHURE TO R]. The purpose of the study is to improve the health and well being of children. [IF ADD’L INFO NEEDED: As the letter says, the information we get from those who take part in the study may help improve child health care and government policies for years to come.] Your household is in one of the areas that has been chosen for the study and earlier we spoke with [CHECK EROCS AND INSERT ENUMERATION RESPONDENT’S NAME].

1A. ASKING FOR ELIGIBLE ADULT FEMALE (AT LEAST AGE OF MAJORITY): Is (ELIGIBLE FEMALE’S NAME) available?

WHEN SPEAKING WITH ADULT ELIGIBLE FEMALE: REPEAT INTRODUCTION IF NEW PERSON, THEN: We told (INSERT ENUMERATION RESPONDENT’S NAME) that we would like to speak with all women ages 18 to 49 or anyone else in the household who is pregnant and (he/she) gave us your name. CONTINUE WITH VOLUNTARY STATEMENT.

1B. ASKING FOR ELIGIBLE MINOR FEMALE: Is (ELIGIBLE FEMALE’S NAME)’s parent or guardian available?

WHEN SPEAKING WITH PARENT/LEGAL GUARDIAN OF PREGNANT MINOR: REPEAT INTRODUCTION IF NEW PERSON, THEN: We told (INSERT ENUMERATION RESPONDENT’S NAME) that we would like to speak with anyone in the household who is pregnant and (he/she) gave us the name (NAME OF MINOR FEMALE). We would like to ask you a few questions about her. Because she is a minor, any questions must be asked of her [PARENT/LEGAL GUARDIAN].

2. VOLUNTARY STATEMENT: I only need a few minutes of your time. It is up to you to decide whether to take part. You can skip over any question I ask or you can stop the interview at any time. The information we collect from you is protected by law and we will keep all of it private. (IF NEEDED: You may be receiving government benefits, such as Social Security or Medicaid. Nothing will happen to those benefits if you decide not to take part in this study.)

 START PREGNANCY SCREENER UNLESS R ASKS QUESTIONS OR REFUSES TO PARTICIPATE.

IF R REFUSES, MAKE EROC ENTRY. COMPLETE ENIRF

PREGNANCY SCREENER (AUDIO CASI) VISIT: SECTION PS

Start Module 1, Section 1

PS001. IS INTERVIEW TO BE CONDUCTED IN PERSON OR VIA PHONE?

IN PERSON 1

PHONE 2

PS001A. ARE YOU SPEAKING TO THE RESPONDENT HERSELF OR A PROXY (I.E., PARENT OR GUARDIAN)?

SELF 1

PROXY 2

PS001B. IS RESPONDENT AN EMANCIPATED MINOR (ALL LOCAL PROCEDURES HAVE BEEN FOLLOWED TO DETERMINE IF MINOR IS EMANCIPATED)?

YES 1

NO 2

PS002. ARE YOU CONTINUING THE PREGNANCY SCREENER ON THE SAME DAY AND WITH THE SAME PERSON WHO COMPLETED THE ENUMERATION?

YES 1

NO 2

PS002A WILL THIS DATA COLLECTION SESSION BE CONDUCTED IN ENGLISH?

YES 1 (BOX PS01)

NO 2

PS002B WHAT OTHER LANGUAGE WILL BE USED TO CONDUCT THIS SESSION?

AMERICAN SIGN LANGUAGE 1 (PS002D)

ARABIC 2 (PS002D)

ARMENIAN 3 (PS002D)

BENGALI 4 (PS002D)

CAMBODIAN 5 (PS002D)

CHAMORRO 6 (PS002D)

CHINESE 7 (PS002D)

CREOLE 8 (PS002D)

CROATIAN (SERBO-CROATIAN) 9 (PS002D)

CZECH 10 (PS002D)

DUTCH 11 (PS002D)

FARSI 12 (PS002D)

FRENCH 13 (PS002D)

GERMAN 14 (PS002D)

GREEK 15 (PS002D)

HINDI 16 (PS002D)

HMONG 17 (PS002D)

HUNGARIAN 18 (PS002D)

ILOCANO 19 (PS002D)

ITALIAN 20 (PS002D)

JAPANESE 21 (PS002D)

KOREAN 22 (PS002D)

LAOTIAN 23 (PS002D)

POLISH 24 (PS002D)

PORTUGUESE 25 (PS002D)

ROMANIAN 26 (PS002D)

RUSSIAN 27 (PS002D)

SAMOAN 28 (PS002D)

SERBIAN (SERBO-CROATIAN) 29 (PS002D)

SLOVAK 30 (PS002D)

SPANISH 31

TAGALOG 32 (PS002D)

THAI 33 (PS002D)

TONGAN 34 (PS002D)

UKRAINIAN 35 (PS002D)

URDU 36 (PS002D)

VIETNAMESE 37 (PS002D)

YIDDISH 38 (PS002D)

OTHER (SPECIFY): 96 (PS002D)

PS002C WILL AN INTERPRETER BE USED?

YES 1

NO 2 (BOX PS01)

PS002D.WHAT TYPE OF INTERPRETER WILL BE USED?

HH MEMBER OR FRIEND 1

DATA COLLECTOR CERTIFIED IN LANGUAGE 2

COMMUNITY VOLUNTEER 3

PROFESSIONAL INTERPRETER 4

OTHER (SPECIFY): 6

BOX PS01

CHECK ITEM:

IF THIS IS NOT A PROXY INTERVIEW AND ENUMERATION ADMINISTERED TO CURRENT RESPONDENT, GO TO BOX PS05.
IF THIS IS A PROXY INTERVIEW WITH THE PARENT OR LEGAL GUARDIAN OF AN ELIGIBLE FEMALE AND THE PREGNANCY SCREENER IS NOT BEING ADMINISTERED ON THE SAME DAY AS THE ENUMERATION WITH THE SAME RESPONDENT (PS002 = ”2”), CONTINUE WITH PS003.
IF THIS IS A PROXY INTERVIEW WITH THE PARENT OR LEGAL GUARDIAN OF AN ELIGIBLE MINOR AND THE PREGNANCY SCREENER IS BEING ADMINISTERED AT THE SAME VISIT AS THE ENUMERATION WITH THE SAME RESPONDENT (PS002 = ”1”), GO TO BOX PS05.
OTHERWISE, CONTINUE WITH PS003.

PS003. OK, {(READ NAME BELOW)}, I’ll begin by confirming some information I have for {(NAME)/you}. How old {are you/is (NAME)}?

INTERVIEWER INSTRUCTION:

IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.

|___|___|

AGE

WRONG CASE 990 (PSCLSE1)

REFUSED 9--97 (EOS)

DON’T KNOW 9--98 (EOS)

BOX PS02

CHECK ITEM:

IF THIS IS A PROXY INTERVIEW, GO TO BOX PS05.
IF NOT A PROXY INTERVIEW AND AGE REPORTED IN PS003 = 18, 19, 20 AND AGE REPORTED IN PS003 IS DIFFERENT THAN AGE REPORTED IN ENUMERATION, CONTINUE WITH PS003A.
OTHERWISE, GO TO BOX PS03.

PS003A. AGE OF RESPONDENT IS DIFFERENT THAN AGE REPORTED IN ENUMERATION AND NEW AGE IS 18 TO 20. FOLLOW LOCAL PROCEDURES TO DETERMINE IF RESPONDENT IS A MINOR REQUIRING A PROXY INTERVIEW. CODE THE APPROPRIATE RESPONSE.

INTERVIEWER INSTRUCTION:

FOLLOW ALL LOCAL PROCEDURES TO DETERMINE IF RESPONDENT IS A MINOR AND IF SO IF SHE IS EMANCIPATED.

R IS AN ADULT (AGE OF MAJORITY OR OLDER) 1

R IS A MINOR REQUIRING PROXY INTERVIEW (NOT

EMANCIPATED) 2 (PSCLSE2)

R IS AN EMANCIPATED MINOR 3

BOX PS03

CHECK ITEM:

IF AGE CONFIRMS ELIGIBILITY (PS003 >=18 AND < 50), CONTINUE WITH PS004.
IF AGE 50 OR OLDER (PS003 >=50) AND REPORTED PREGNANT IN ENUMERATION (EN021, EN026, OR EN031 =”1”), CONTINUE WITH PS004.
IF AGE LESS THAN 18 (PS003 <18) AND FEMALE IS EMANCIPATED (PS001B = “1”), CONTINUE WITH PS004.
IF AGE LESS THAN 18 (PS003 <18) AND FEMALE IS NOT EMANCIPATED (PS001B = “2”), AND REPORTED PREGNANT IN ENUMERATION (EN021, EN026, OR EN031 = “1”), GO TO PSCLSE2.
IF AGE LESS THAN 18 (PS003 < 18) AND FEMALE IS NOT EMANCIPATED (PS001B = “2”), AND NOT REPORTED PREGNANT IN ENUMERATION (EN021, EN026, OR EN031) ≠ “1”), GO TO EOS.
OTHERWISE, IF AGE 50 OR OLDER (PS003 >=50) AND NOT PREGNANT ON ENUMERATION (EN021, EN026, OR EN031) ≠ “1”), GO TO EOS.

PS004. What is your address?

STREET NUMBER: {StreetNo} PRE DIRECTIONAL: {PreDir} STREET NAME: {Street} STREET TYPE: {StTypeID} POST DIRECTIONAL: {PostDir}

UNIT TYPE: {UnitTypeID} UNIT NUMBER: {UnitNo}

CITY: {City}

STATE: {State}

ZIP CODE: {Zip} 4-DIGIT ZIP CODE EXTENSION: {ZipPlus4}

YES, CORRECT ADDRESS 1 (BOX PS05)

YES (BUT WITH MINOR CORRECTIONS) 2 (PS006)

NO (WRONG ADDRESS) 3 (PSCLSE1)

REFUSED 9--97 (EOS)

DON’T KNOW 9--98 (EOS)

PS006. INTERVIEWER INSTRUCTION:

CONFIRM CORRECTIONS WITH RESPONDENT.

STREET NUMBER: {StreetNo} PRE DIRECTIONAL: {PreDir} STREET NAME: {Street} STREET TYPE: {StTypeID} POST DIRECTIONAL: {PostDir}

UNIT TYPE: {UnitTypeID} UNIT NUMBER: {UnitNo}

CITY: {City}

STATE: {State}

ZIP CODE: {Zip} 4-DIGIT ZIP CODE EXTENSION: {ZipPlus4}

REFUSED 9--97

DON’T KNOW 9--98

BOX PS05

CHECK ITEM:

IF THIS IS A PROXY INTERVIEW CONDUCTED WITH THE PARENT OR LEGAL GUARDIAN OF AN ELIGIBLE MINOR, CONTINUE WITH PS006A.
IF NOT A PROXY INTERVIEW AND R SAME RESPONDENT AS ENUMERATION AND SHE REPORTED HERSELF PREGNANT IN ENUMERATION, AND AGE 21 OR OLDER, GO TO PS007.
IF NOT A PROXY INTERVIEW AND R SAME RESPONDENT AS ENUMERATION AND SHE REPORTED HERSELF PREGNANT IN ENUMERATION, AND UNDER 21, CONTINUE WITH PS006A.
IF NOT A PROXY INTERVIEW AND PREGNANCY SCREENER ADMINISTERED ON THE SAME DAY WITH THE SAME PERSON WHO COMPLETED THE ENUMERATION AND SHE REPORTED HERSELF AS NOT PREGNANT IN ENUMERATION AND AGE 21 OR OLDER, GO TO PS013.
IF NOT A PROXY INTERVIEW AND PREGNANCY SCREENER ADMINISTERED ON THE SAME DAY WITH THE SAME PERSON WHO COMPLETED THE ENUMERATION AND SHE REPORTED HERSELF AS NOT PREGNANT IN ENUMERATION AND AGE UNDER 21, GO TO PS012.
OTHERWISE, GO TO PS012.

PS006A. We are asking {women} a few questions about pregnancy, sexual activity and birth control. Only a small number of women who answer these questions will be chosen to take part in the National Children’s Study now, but almost every woman who answers these questions will have a chance to take part in some way in the future. If {you are/(NAME) is} chosen to be in one of the groups we need for the study now, I will give you more information to help decide whether you want her to take part in it.

{Answering these questions is your choice. Please keep in mind that your answers to these questions are very important. The information we collect from you is protected by law and we will keep all of it private.}

DISPLAY INSTRUCTIONS:

IF PROXY INTERVIEW (PS001A) = “2” DISPLAY “{(NAME) is}“ AND “{Answering these questions is your choice. Please keep in mind that your answers to these questions are very important. The information we collect is protected by law and we will keep all the information private.} DISPLAY FIRST NAME OF ELIGIBLE FEMALE ACCORDING TO ENUMERATION (EN018, EN023, OR EN028) for “{NAME}”.

OTHERWISE, DISPLAY “{woman}” AND “{you are}”.

PS007. {You told me earlier that you are/As we discussed earlier, {NAME} is} pregnant. When is the baby due?

|___|___| |___|___| |___|___|___|___|

MM DD YYYY

NO LONGER PREGNANT 9--90

REFUSED 9--97

DON’T KNOW 9--98

BOX PS06

CHECK ITEM:

IF PROXY INTERVIEW WITH PARENT/LEGAL GUARDIAN AND ANSWERED REFUSED OR DON’T KNOW TO BABY’S DUE DATE, GO TO PS009.
IF NO LONGER PREGNANT, GO TO EOS.
IF PREGNANCY STATUS MISCODED AT ENUMERATION AND EITHER A PROXY INTERVIEW OR NOT A PROXY INTERVIEW AND AGE 50 OR OLDER, GO TO EOS.
IF PREGNANCY STATUS MISCODED AT ENUMERATION AND NOT A PROXY INTERVIEW AND AGE LESS THAN 50, GO TO PS012.
IF VALID DATE ENTERED IN PS007, GO TO EOS.
OTHERWISE, CONTINUE WITH PS008.

PS008. What was the first day of your last menstrual period?

|___|___| |___|___| |___|___|___|___|

MM DD YYYY

REFUSED 9--97 (PS009)

DON’T KNOW 9--98 (PS009)

BOX PS07

GO TO EOS.

PS009. About how many weeks pregnant {are you/is {NAME}}? If you’re not sure, please make your best guess.

|___|___|

NUMBER OF WEEKS

REFUSED 9--97 (PS010)

DON’T KNOW 9--98 (PS010)

BOX PS08

GO TO EOS.

PS010. About how many months pregnant {are you/is {NAME}}? If you’re not sure, please make your best guess.

|___|___|

NUMBER OF MONTHS

REFUSED 9--97 (PS011)

DON’T KNOW 9--98 (PS011)

BOX PS09

GO TO EOS.

PS011. {Are you/Is {NAME}} currently in {your/her} 1^st, 2^nd, or 3^rd trimester?

1^ST Trimester (1 to 3 months pregnant) 1

2^ND Trimester (4 to 6 months pregnant) 2

3^RD Trimester (7 to 9 months pregnant) 3

REFUSED 9--97

DON’T KNOW 9--98

BOX PS10

GO TO EOS.

PS012. {Now, I have a few questions for you to answer on your own that will help decide how you can take part in the National Children’s Study. This should take about 5 minutes.}

We are asking women questions about pregnancy, sexual activity and birth control. Only a small number of women who answer these questions can take part in the National Children’s Study now, but almost every woman who answers these questions will have a chance to take part in some way in the future. If you are chosen to be in one of the groups we need for the study now, I will give you more information to help decide whether you want to take part in it.

{Some women may consider questions about sexual activity or birth control to be personal, so I’ll give you headphones to listen to the questions. You will enter your responses into the computer by touching the screen. This will allow you to answer questions in complete privacy. The computer will determine if you are eligible for the Study.

It would be best if you could sit down in a chair or at a table while answering these questions. Please let me know where a comfortable spot would be to get you set up.}

PS013. OK, I’d now like to give you some important information. Answering these questions is your choice. {Some women may consider questions about sexual activity or birth control to be personal.} You can skip over any question I ask or you can stop the interview at any time. Please keep in mind that your answers to these questions are very important. The information we collect from you is protected by law and we will keep all of it private. (IF NEEDED: You may be receiving government benefits, such as Social Security or Medicaid. Nothing will happen to those benefits if you decide not to take part in this study.) OK, let’s get started.

PS014. QUESTION DELETED

PS015. The National Children’s Study is enrolling women of child-bearing age to get information about pregnancy. These questions will help us to see if you can take part in the Study. Answering them does not mean that you agree to be part of the Study.

BOX PS11

GO TO EOS.

PSCLSE1. It looks like I may have selected the wrong case. It will take just a moment while I check in the computer.

INTERVIEWER INSTRUCTIONS:

EXIT THE PREGNANCY SCREENER AND SELECT THE CORRECT CASE AND/OR ADDRESS FROM YOUR ASSIGNMENT LIST.

BOX PS12

GO TO EOS.

PSCLSE2. Thank you. Since you are a minor, I must speak with one of your parents or a legal guardian. Is one of your parents or a legal guardian available to talk right now?

EOS

START OF AUDIO CASI

Start Module 2, Section 1

BOX PS15

IF WOMAN NO LONGER PREGNANT AND A PROXY INTERVIEW OR NOT A PROXY INTERVIEW AND AGE 50 OR OLDER, GO TO BOX PS26A.
IF SPEAKING WITH PARENT OR LEGAL GUARDIAN, GO TO BOX PS26A.
IF R SAME RESPONDENT AS ENUMERATION AND SHE REPORTED HERSELF PREGNANT IN THE ENUMERATION, GO TO BOX PS26A.
IF MODULE 1, SECTION 1 STATUS = “PARTIAL” OR “NOT DONE”, CASE IS NOT ELIGIBLE FOR MODULE 2. GO TO MODULE 3.
IF THE INTERVIEW IS BEING CONDUCTED BY PHONE OR WITH AN INTERPRETER, CASE IS NOT ELIGIBLE FOR MODULE 2, SECTION 1. GO TO MODULE 2, SECTION 2.
IF AGE LESS THAN 18 AND NOT REPORTED PREGNANT IN ENUMERATION, GO TO BOX PS26A.
IF AGE 50 OR OLDER AND NOT REPORTED PREGNANT IN ENUMERATION, GO TO BOX PS26A.
OTHERWISE, CONTINUE WITH PS016.

PS016. The first three questions are practice questions and are not part of the study. They will help you learn how to use this computer and you do not need to wear the headphones while listening to them. Remember that you need to press the ‘NEXT’ button after you have answered each question. If at any time you make a mistake answering a question, you can press the ‘CLEAR’ button to erase your answer and then select the correct answer. Press ‘NEXT’ to see the first practice question.

PS017. What is your favorite soft drink?

RESPONDENT INSTRUCTION:

“Use the stylus to select your answer. Press ‘NEXT’ when you are done.”

Coke 1

Pepsi 2

Sprite 3

7-Up 4

Another soft drink 5

REFUSED 9--97

DON’T KNOW 9--98

PS018. During a typical week, how many movies do you watch?

RESPONDENT INSTRUCTION:

“Use the keypad to enter the number and press ‘NEXT’ when you are done.”

|___|___|

NUMBER OF MOVIES

REFUSED 9--97

DON’T KNOW 9--98

PS019. What is today’s date?

RESPONDENT INSTRUCTION:

“Use the keypad to enter today’s date, starting with the 2-digit month, next the 2-digit day and lastly the 4-digit year. Press ‘NEXT’ when you are done.”

|___|___| |___|___| |___|___|___|___|

MM DD YYYY

REFUSED 9--97

DON’T KNOW 9--98

PS020. You have now completed the practice questions and are ready to begin the study questions. If at any point, you don’t know the answer to a question or prefer not to answer, press the ‘NEXT’ button without selecting an answer and follow the computer’s instructions. Let your interviewer know if you need help while answering the questions on your own.

Please put on your headphones now. Your interviewer will help you adjust the volume. When you are ready, press ‘NEXT’ to see the first question.

INTERVIEWER INSTRUCTION:

GIVE RESPONDENT HEAD PHONES AND ADJUST VOLUME.

EOS

END MODULE 2, SECTION 1.

Start Module 2, Section 2

BOX PS16

CHECK ITEM:

IF PREGNANCY SCREENER ADMINISTERED ON SAME DAY AND WITH THE SAME PERSON WHO COMPLETED THE ENUMERATION, GO TO BOX PS17.
OTHERWISE, CONTINUE WITH PS021.

PS021. Are you pregnant now?

Yes 1

No 2

REFUSED 9--97

DON’T KNOW 9--98

BOX PS17

CHECK ITEM:

IF R LAST REPORTED PREGNANT IN PREGNANCY SCREENER, GO TO PS023.
IF R LAST REPORTED PREGNANT IN ENUMERATION AND PS021 IS NOT ASKED, GO TO PS023.
IF R LAST REPORTED NOT PREGNANT IN THE PREGNANCY SCREENER, GO TO BOX PS17A.
IF R LAST REPORTED NOT PREGNANT IN THE ENUMERATION, AND PS021 IS NOT ASKED, GO TO PS028.
IF R LAST REPORTED SHE DOESN’T KNOW IF PREGNANT OR REFUSED TO ANSWER IN THE PREGNANCY SCREENER, CONTINUE WITH PS022.
OTHERWISE, IF R LAST REPORTED SHE DOESN’T KNOW IF PREGNANT OR REFUSED TO ANSWER IN THE ENUMERATION, AND PS021 IS NOT ASKED, CONTINUE WITH PS022.

BOX PS17A

CHECK ITEM:

IF R LAST REPORTED AGE IN PREGNANCY SCREENER AND AGE 49 OR YOUNGER, GO TO PS028.
IF R LAST REPORTED AGE IN ENUMERATION AND AGE 49 OR YOUNGER, GO TO PS028.
IF R LAST REPORTED AGE IN PREGNANCY SCREENER, AND AGE 50 OR OLDER, GO TO PS035.
OTHERWISE, IF R LAST REPORTED AGE IN ENUMERATION AND AGE 50 OR OLDER, GO TO PS035.

PS022. Do you think you are probably pregnant or not?

Yes, probably pregnant 1

No, probably not pregnant 2 (PS028)

REFUSED 9--97 (PS028)

DON’T KNOW 9--98 (PS028)

PS023. When is your baby due?

RESPONDENT INSTRUCTION:

“Use the keypad to enter your baby’s due date, starting with the 2-digit month, next the 2-digit day and lastly the 4-digit year. Press ‘NEXT’ when you are done.”

|___|___| |___|___| |___|___|___|___|

MM DD YYYY

REFUSED 9--97

DON’T KNOW 9--98

BOX PS18

CHECK ITEM:

IF PS023 = “9--97” OR “9--98”, CONTINUE WITH PS024.
OTHERWISE, GO TO PS035.

PS024. What was the first day of your last menstrual period?

RESPONDENT INSTRUCTION:

“Using the keypad, enter the 2-digit month in which you started your last menstrual period, next the 2-digit day you started your last menstrual period and lastly the 4-digit year. Press ‘NEXT’ when you are done.”

|___|___| |___|___| |___|___|___|___|

MM DD YYYY

REFUSED 9--97 (PS025)

DON’T KNOW 9--98 (PS025)

BOX PS19

GO TO PS035.

PS025. About how many weeks pregnant are you? If you’re not sure, please make your best guess.

RESPONDENT INSTRUCTION:

Enter the number of weeks using the keypad.

|___|___|

NUMBER OF WEEKS

REFUSED 9--97 (PS026)

DON’T KNOW 9--98 (PS026)

BOX PS20

GO TO PS035.

PS026. About how many months pregnant are you? If you’re not sure, please make your best guess.

RESPONDENT INSTRUCTION:

Enter the number of months using the keypad.

|___|___|

NUMBER OF MONTHS

REFUSED 9--97 (PS027)

DON’T KNOW 9--98 (PS027)

BOX PS21

GO TO PS035.

PS027. Are you currently in your 1^st, 2^nd, or 3^rd trimester?

1^ST Trimester (1 to 3 months pregnant) 1

2^ND Trimester (4 to 6 months pregnant) 2

3^RD Trimester (7 to 9 months pregnant) 3

REFUSED 9--97

DON’T KNOW 9--98

BOX PS22

GO TO PS035.

PS028. Are you currently trying to become pregnant?

Yes 1

No 2 (PS030)

REFUSED 9--97 (PS030)

DON’T KNOW 9--98 (PS030)

PS029. How many months have you been trying to become pregnant?

1 Month 1

2 Months 2

3 Months 3

4 Months 4

5 Months 5

6 Months 6

7 Months 7

8 Months 8

9 Months 9

10 Months 10

11 Months 11

12 To 24 Months 12

More Than 24 Months 13

REFUSED 9--97

DON’T KNOW 9--98

BOX PS23

GO TO PS035.

PS030. Do any of the following apply to you? Have you had:

A hysterectomy,
Both ovaries removed,
Your tubes tied, or
Gone through menopause?

Yes 1 (PS035)

No 2

REFUSED 9--97

DON’T KNOW 9--98

BOX PS24

IF RESPONDENT IS AGE 45-49 AND R IS THE ENUMERATION R AND THIS IS NOT A PROXY INTERVIEW, GO TO PS035.
OTHERWISE, CONTINUE WITH PS031.

PS031. Because this study is enrolling women who may become pregnant, it is important to know if you are sexually active. Have you had sexual intercourse with a man in the past 3 months?

Yes 1

No 2 (PS035)

REFUSED 9--97 (PS035)

DON’T KNOW 9--98 (PS035)

PS032. Has your current sexual partner had a vasectomy?

Yes 1 (PS035)

No 2

Not sure 3

REFUSED 9--97

DON’T KNOW 9--98

PS033. Now I have a few questions about birth control. The last time you had intercourse with a man, did you use any type of birth control or do anything to prevent pregnancy?

Yes 1

No 2 (PS035)

REFUSED 9--97 (PS035)

DON’T KNOW 9--98 (PS035)

PS034. What type of birth control did you use the last time you had intercourse with a man?

RESPONDENT INSTRUCTION:

If you make a mistake, press the ‘CLEAR’ button to re-enter your answer. Press the ‘NEXT’ button when you have finished answering the question.

Birth control pills 1

Condoms 2

Depo-Provera/shots/injections 3

Diaphragm/cap/shield 4

Natural family planning, including rhythm or safe period by calendar,

temperature, or cervical mucus 5

Foam/jelly/cream/insert 6

Female condom/vaginal pouch 7

Patch/Nuva ring 8

TODAY sponge 9

Withdrawal/pulling out 10

IUD/Coil/Loop 11

Plan B/“Morning After” pill 12

Norplant 13

Some other method 96

REFUSED 9--97

DON’T KNOW 9--98

PS035. Thank you for answering these questions. {Please let your interviewer know that you are done.}

PS035A. ENTER SECURITY CODE TO CONTINUE.

EOS

END MODULE 2, SECTION 2.

END OF AUDIO CASI

BOX PS27

RUN ALGORITHM AND ASSIGN PROBABILITY OF PREGNANCY GROUP (PPG).

Start Module 3, Section 1

BOX PS27A

IF MODULE 2, SECTION 1 WAS ADMINISTERED, CONTINUE WITH PS036.
OTHERWISE, GO TO BOX PS29.

PS036 - Repossess computer

REARRANGE COMPUTER FOR INTERVIEWER USE.
PUT AWAY EARPHONES AND DISPOSE OF EARPHONE COVERS.
SELECT ‘NEXT’ TO CONTINUE. THE COMPUTER WILL RUN THE ALGORITHM AND ASSIGN THE WOMAN TO A GROUP.

BOX PS29

CHECK ITEM:

IF IN NO FOLLOW UP GROUP AND UNDER AGE OF MAJORITY AND PREGNANT IN ENUMERATION AND STILL PREGNANT AT PREGNANCY SCREENER, GO TO PS042.
IF IN PREGNANT ELIGIBLE GROUP AND UNDER AGE OF MAJORITY, GO TO PS042.
IF IN HOLDING GROUP AND NO LONGER PREGNANT, GO TO PS042.
IF IN NO FOLLOW UP GROUP AND NO LONGER PREGNANT AND UNDER AGE OF MAJORITY, GO TO PSCLSE10.
IF IN NO FOLLOW UP GROUP AND PREGNANCY STATUS MISCODED AT ENUMERATION AND A PROXY INTERVIEW, GO TO PSCLSE10.
OTHERWISE, CONTINUE WITH BOX PS29A.

BOX PS29A

CHECK ITEM:

IF NCS AWARENESS QUESTIONS PREVIOUSLY ASKED, GO TO PS042.
OTHERWISE, CONTINUE WITH PS037.

PS037. The computer will now process your answers. While we wait, I’ll ask you some questions about how you heard of our study.

PS038. Before today, had you heard about the National Children’s Study?

YES 1

NO 2 (PS042)

REFUSED 9--97 (PS042)

DON’T KNOW 9--98 (PS042)

PS039. How did you hear about the National Children’s Study?

INTERVIEWER INSTRUCTION:

SELECT ALL THAT APPLY.

FRIENDS OR ACQUAINTANCES 1

FAMILY MEMBERS 2

CHURCH, SYNAGOGUE, OR OTHER RELIGIOUS AFFILIATION 3

A COMMUNITY LEADER 4

SOMEONE ELSE IN THE COMMUNITY (OTHER THAN THE
NCS RESEARCHERS) 5

DOCTOR OR HEALTH CARE PROVIDER 6

NEWSPAPER, T.V., OR RADIO 7

BILLBOARD 8

INTERNET OR WEBSITE 9

A LETTER IN THE MAIL 10

OTHER (SPECIFY): 11

REFUSED 9--97

DON’T KNOW 9--98

PS040. Have you taken part in any local or community activities sponsored by the National Children’s Study such as town meetings, community forums, community advisory boards, health fairs, or other activities?

YES 1

NO 2 (PS041m)

REFUSED 9--97 (PS041m)

DON’T KNOW 9--98 (PS041m)

PS041. Would you describe the event as:

A health fair, that is an event with informational or health monitoring booths;
A meeting with at least one speaker who presents information to an audience;
A discussion group with a limited number of people participating;
Or something else?

HEALTH FAIR 1

MEETING 2

DISCUSSION GROUP 3

SOMETHING ELSE (SPECIFY): 4

REFUSED 9--97

DON’T KNOW 9--98

PS041m.Have you seen any part of a video titled “The National Children’s Study – Health, Growth, Environment”?

YES 1

NO 2 (PS042)

REFUSED 9--97 (PS042)

DON’T KNOW 9--98 (PS042)

PS041t. Since you’ve seen a part of the video, we are interested in how you found out about it? Did you…

Receive a DVD in the mail, 1

Receive a DVD delivered to you in-person, 2

Receive a DVD at an event or meeting, 3

Receive a letter with a web address for the video, 4

Hear about the web address for the video at an event or meeting, or 5

Find the video while searching at the NCS Website? 6

OTHER (SPECIFY): 7

REFUSED 9--97

DON’T KNOW 9--98

PS042. These next few questions will help us to contact you again in the future.

BOX PS30

CHECK ITEM:

IF R WAS ENUMERATION RESPONDENT, GO TO PS046.
OTHERWISE, CONTINUE WITH PS043.

PS043. What is your name?

INTERVIEWER INSTRUCTION:

CONFIRM SPELLING OF FIRST NAME IF NOT PREVIOUSLY COLLECTED AND OF LAST NAME FOR ALL RESPONDENTS.

_____________________ ___________________

FIRST NAME LAST NAME

REFUSED 9--97

DON’T KNOW 9--98

PS044. What is the best phone number to reach you?

INTERVIEWER INSTRUCTION:

ENTER PHONE NUMBER AND CONFIRM.

|___|___|___| - |___|___|___| - |___|___|___|___|

REFUSED 9--97 (PS047)

DON’T KNOW 9--98 (PS048)

PS045. Is that your home, work, cell, or another phone number?

INTERVIEWER INSTRUCTION:

CONFIRM IF KNOWN.

HOME 1

WORK 2

CELL 3 (PS047)

FRIEND/RELATIVE (SPECIFY): 4

OTHER (SPECIFY): 5

REFUSED 9--97

DON’T KNOW 9--98

PS046. What is your cell number?

INTERVIEWER INSTRUCTION:

ENTER PHONE NUMBER AND CONFIRM.

|___|___|___| - |___|___|___| - |___|___|___|___|

NO CELL NUMBER 9--90 (PS047)

REFUSED 9--97 (PS047)

DON’T KNOW 9--98 (PS047)

BOX PS30A

CHECK ITEM:

IF R PROVIDED CELL NUMBER, GO TO PS047.
OTHERWISE, CONTINUE WITH PS046A.

PS046A. What is another phone number where we can reach you?

INTERVIEWER INSTRUCTION:

ENTER PHONE NUMBER AND CONFIRM.

|___|___|___| - |___|___|___| - |___|___|___|___|

AREA CODE PHONE NUMBER

NO ADDITIONAL PHONE NUMBER 9--90 (PS047)

REFUSED 9--97 (PS047)

DON’T KNOW 9--98 (PS047)

PS046B. Is that a home, work, cell, or another phone number?

INTERVIEWER INSTRUCTION:

CONFIRM IF KNOWN.

HOME 1

WORK 2

CELL 3

FRIEND/RELATIVE (SPECIFY): 4

OTHER (SPECIFY): 5

REFUSED 9--97

DON’T KNOW 9--98

PS047. Is your mailing address the same as your street address?

YES 1 (PS049)

NO 2

REFUSED 9--97 (PS049)

DON’T KNOW 9--98 (PS049)

PS048. What is your mailing address?

INTERVIEWER INSTRUCTION:

PROMPT AS NECESSARY TO COMPLETE INFORMATION

_____________________________________________________

STREET/PO BOX

_____________________________________________________

CITY

|___|___| |___|___|___|___|___|

STATE ZIP CODE

REFUSED 9--97

DON’T KNOW 9--98

PS049. What is {your/(NAME’s)} birthdate?

|___|___| |___|___| |___|___|___|___|

MM DD YYYY

REFUSED 9--97

DON’T KNOW 9--98

BOX PS31

CHECK ITEM:

IF IN NO FOLLOW UP GROUP AND 18 OR OLDER, GO TO PSCLSE9.
IF IN NO FOLLOW UP GROUP AND PROXY INTERVIEW AND PREGNANT IN ENUMERATION AND STILL PREGNANT AT PREGNANCY SCREENER, GO TO PSCLSE13.
OTHERWISE, CONTINUE WITH PS050.

PS050. Do you have an email address?

YES 1

NO 2 (BOX PS32)

REFUSED 9--97 (BOX PS32)

DON’T KNOW 9--98 (BOX PS32)

PS051. What is the best email address to reach you?

___________________________________

REFUSED 9--97 (BOX PS32)

DON’T KNOW 9--98 (BOX PS32)

PS051m.Is that your personal e-mail, work e-mail, or a family or shared e-mail address?

PERSONAL 1

WORK 2

FAMILY/SHARED 3

REFUSED 9--97

DON’T KNOW 9--98

BOX PS32

CHECK ITEM:

IF IN PREGNANT ELIGIBLE GROUP AND ABOVE AGE OF MAJORITY, CONTINUE WITH PS052.
IF IN PREGNANT ELIGIBLE GROUP AND BELOW AGE OF MAJORITY, GO TO PSCLSE12.
IF IN HOLDING GROUP AND PREGNANT, GO TO PSCLSE5.
IF IN HOLDING GROUP AND NO LONGER PREGNANT, GO TO PSCLSE14.
IF IN HIGH NON-TRYER OR HIGH TRYER GROUP, GO TO PS058.
IF IN MODERATE/LOW GROUP, GO TO PSCLSE7.
IF IN EXTRA LOW GROUP, GO TO PSCLSE8.

PS052. Do you plan on moving from your present address before you have your baby?

YES 1

NO 2 (PSCLSE4)

REFUSED 9--97 (PSCLSE4)

DON’T KNOW 9--98 (PSCLSE4)

PS053. Do you know where you will be moving?

YES 1

NO 2 (PS056)

REFUSED 9--97 (PS056)

DON’T KNOW 9--98 (PS056)

PS054. What is the address of your new home?

ADDRESS GIVEN 1

OUT OF THE COUNTRY 0 (PS056)

PO BOX ADDRESS ONLY 6 (PS056)

REFUSED 9--97 (PS056)

DON’T KNOW 9--98 (PS056)

PS055.

INTERVIEWER INSTRUCTION: PROBE AND ENTER AS MUCH INFORMATION AS R KNOWS.

_____________________________________________________

STREET ADDRESS

_____________________________________________________

CITY

|___|___| |___|___|___|___|___|

STATE ZIP CODE

PS056. Do you know when you will be moving?

YES 1

NO 2 (BOX PS33)

REFUSED 9--97 (BOX PS33)

DON’T KNOW 9--98 (BOX PS33)

PS057. When will you move?

INTERVIEWER INSTRUCTION:

CONFIRM IF KNOWN.

ENTER AS MUCH AS R KNOWS.

|___|___| |___|___| |___|___|___|___|

MM DD YYYY

REFUSED 9--97

DON’T KNOW 9--98

BOX PS33

CHECK ITEM:

IF MOVING AND KNOW WHERE MOVING TO, GO TO PSCLSE11.
OTHERWISE, GO TO PSCLSE4.

PS058. Do you plan on moving from your present address within the next two months?

YES 1

NO 2 (PSCLSE6)

REFUSED 9--97 (PSCLSE6)

DON’T KNOW 9--98 (PSCLSE6)

PS059. Do you know where you will be moving?

YES 1

NO 2 (PS062)

REFUSED 9--97 (PS062)

DON’T KNOW 9--98 (PS062)

PS060. What is the address of your new home?

ADDRESS GIVEN 1

OUT OF THE COUNTRY 0 (PS062)

PO BOX ADDRESS ONLY 6 (PS062)

REFUSED 9--97 (PS062)

DON’T KNOW 9--98 (PS062)

PS061.

INTERVIEWER INSTRUCTION: PROBE AND ENTER AS MUCH INFORMATION AS R KNOWS.

_____________________________________________________

STREET ADDRESS

_____________________________________________________

CITY

|___|___| |___|___|___|___|___|

STATE ZIP CODE

PS062. Do you know when you will be moving?

YES 1

NO 2 (BOX PS34)

REFUSED 9--97 (BOX PS34)

DON’T KNOW 9--98 (BOX PS34)

PS063. When will you move?

INTERVIEWER INSTRUCTION:

CONFIRM IF KNOWN.

ENTER AS MUCH AS R KNOWS.

|___|___| |___|___| |___|___|___|___|

MM DD YYYY

REFUSED 9--97

DON’T KNOW 9--98

BOX PS34

CHECK ITEM:

IF MOVING WITHIN TWO MONTHS AND KNOW WHERE MOVING TO, GO TO PSCLSE11.
OTHERWISE, GO TO PSCLSE6.

PSCLSE4. Thank you for answering these questions. You have been chosen to be part of this important study because of your due date. The next step for the group you’re in is a home visit. I would like to tell you more about it and give you all the information you need to decide if you would like to be part of the study.

INTERVIEWER INSTRUCTIONS:

FOLLOW PROCEDURES FOR CONSENT PROCESS.

BOX PS35

GO TO EOS.

PSCLSE5. Thank you for answering these questions. You are too far along in your pregnancy to be part of this study now, but we will get in touch with you about six months after your baby is born to update your information. If you become pregnant again, you may be able to be part of the study.

BOX PS36

GO TO EOS.

PSCLSE6. Thank you for answering these questions. Based on what you’ve told me, you have been chosen to be part of this important study. You are in a group that we will stay in touch with by phone and we will be calling you in a month or two.

INTERVIEWER INSTRUCTION:

INDIVIDUAL IN HIGH {TRYER/NON-TRYER} GROUP
{ELIGIBLE FOR P1 VISIT/ NOT ELIGIBLE FOR P1 VISIT}.
AS APPLICABLE, FOLLOW CURRENT PROCEDURES FOR CONSENT, PREGNANCY KITS AND INFORMING R OF NEXT STEPS.

BOX PS37

GO TO EOS.

PSCLSE7. Thank you for answering these questions. Right now, you are not in one of the groups we need for the study, but you may be in the future. We will give you a call in a month or two to update your information.

INTERVIEWER INSTRUCTION:

PROVIDE STUDY BROCHURE IF NEEDED.

BOX PS38

GO TO EOS.

PSCLSE8. Thank you for answering these questions. Right now, you are not in one of the groups we need for the study, but you may be in the future. We will give you a call in about six months to update your information.

INTERVIEWER INSTRUCTION:

PROVIDE STUDY BROCHURE IF NEEDED.

BOX PS39

GO TO EOS.

PSCLSE9. {Thank you for answering these questions. Based on what you’ve told me, you are not in one of the groups that we need for this study and we will not ask you to take part in it at this time./I’m so sorry to hear that you’ve lost your baby. I know this can be a hard time. Based on what you’ve told me, we will not ask you to take part in the study.} Because your address is part of the study, we may be back in touch at a later time to update your household information. Thank you for your time.

BOX PS40

GO TO EOS.

PSCLSE10. Thanks for letting me know. Based on what you’ve told me, {NAME} is not in one of the groups we need for this study and we will not ask her to take part in it. Because your address is part of the study, we may be back in touch at a later time to update your household information. Thank you for your time.

BOX PS41

GO TO EOS.

PSCLSE11. Since you will be moving soon, I need to talk with my supervisor to see if you can take part in this study. If you can, I will be back in touch with you soon to let you know.

BOX PS42

GO TO EOS.

PSCLSE12. {NAME} has been chosen to be part of this important study. I would like to tell you and her more about it and give you all the information you need to decide if she would like to be part of the study.

INTERVIEWER INSTRUCTION:

FOLLOW PROCEDURES FOR CONSENT/ASSENT PROCESS.

BOX PS43

GO TO EOS.

PSCLSE13. Thank you for answering these questions. {NAME} is not in one of the groups we need for this study because of her due date and we will not ask her to take part in it. Because your address is part of the study, we may be back in touch at a later time to update your household information.

BOX PS44

GO TO EOS.

PSCLSE14. I’m so sorry to hear that you’ve lost your baby. I know this can be a hard time. We will be in touch again in about six months to see how you’re doing and update your information. Thanks for your time.

PS END

END PREGNANCY SCREENER.

Revised 7/2/08

File Type	application/msword
File Title	CONSENT FOR PREGNANCY SCREENER
File Modified	2008-09-09
File Created	2008-09-09