Form 1 Survey

OMB #: 0925-0593

Expiration Date: xx/xxxx

JULY LAUNCH VERSION

VERSION 7/14/2010

Recruitment Strategy Substudy

Enhanced Household Group

Household Enumeration Script

TABLE OF CONTENTS

CAPI

VERBAL CONSENT TO SCREENING FOR STUDY ELIGIBILITY

General Eligibility Questions

Household Roster

Summary of Women in Housheold

Hidden Dwelling Units

TRACING QUESTIONS

Summary of Eligibility Status

Interviewer-Completed Questions

NOTE: Questionnaire and other required text is shown in regular font. Interviewer instructions and text not to be read to respondents is shown in ALL CAPS. Introductory text that may or may not be appropriate for all recruitment strategies is shaded. Variable names are shown in BOLD CAPS.

DOCUMENT HISTORY

DATE	VERSION	SUMMARY OF CHANGE/MILESTONE
….	20100430	GRABER INITIAL DRAFT, J. PARK INITIAL FORMATTING FOR LINEAR REVIEW
5/6/2010 AM	20100430	DISCUSSED WITH OMB
5/6/2010 PM	20100430_JG EDITS	COMMENTS FROM CC
5/9/2010	20100509	J. PARK/GRABER ADJUDICATION; APPLY NEW INSTRUMENT FORMAT TO SECTION AD FOR COMMENT
5/10/2010	20100510	REMOVE REFERENCE TO CATI; RESTORE TO WORKING INSTRUMENT FORMAT FOR INTERNAL CONSISTENCY
		POST ON PORTAL FOR NCS PO/NCS COMMENTS
5/23/2010	20100521	INCORPORATE OMB COMMENTS AND NCS COMMENTS, RECONCILE WITH INSTRUMENT FORMAT OF 05/07/10
5/26/2010	20100521_jj	INCORPORATE SOURCES
5/27/2010	20100527	INCORPORATE EDITS FROM IRB TEAM
5/28/2010	20100527	RECONCILE / ACCEPT CHANGES
6/1/2010	20100527	GRABER REVIEW
6/2/2010	20100602	COMMENTS FROM GRABER, BRENNER, SCHOENDORF, J. PARK, HAUGEN, HIRSCHFELD, SLUTSMAN CHANGE ELIGIBILITY AND ROUTING TO AGE OF MAJORITY TO AGE 49, NO EMANCIPATED MINORS [TO BE CORRECTED – HIGHLIGHTED HERE]
6/7/2010	20100607	INCORPORATE COMMENTS FROM J. PARK
6/7/2010	20100607a	INCORPORATE COMMENTS FROM J. SLUTSMAN
6/9/2010	20100607a	SUBMIT TO OMB (FORMAL)
6/9/2010	20100609	Graber review
6/21/2010	20100621_TCA	Tracked changes accepted
6/25/2010	20100625	Integrated changes from Slutsman, Schoendorf, and Park
6/28/2010	20100628	Revisions saved
7/14/2010	20100714	Accept format changes
7/15/2010	20100714	SUBMISSION TO OMB
		SUBMIT TO NCS IRB
		RECONCILE WITH DATA ELEMENTS TABLE

NOTE: Italics denote anticipated development stages.

CAPI

VERBAL CONSENT TO SCREENING FOR STUDY ELIGIBILITY

(TIME_STAMP_1). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

INTERVIEWER INSTRUCTION: IF SOMEONE WHO APPEARS TO BE UNDER THE LOCAL AGE OF MAJORITY ANSWERS THE DOOR, ASK TO SPEAK WITH AN ADULT BEFORE PROCEEDING WITH THE INTRODUCTION.

AD001. Hello, I’m [INTERVIEWER 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.

AD002. I only need a few minutes of your time. Even if there are no children living at this address, it’s important to see if anyone in your household may be able to take part in the study. Can we ask you some questions to see if anyone in the household may be able to take part in the Study? You can skip over any question I ask and we can stop at any time. The information we collect from you is protected by law and we will keep all of it private.

INTERVIEWER INSTRUCTION: IF NEEDED, SAY:

You may be receiving government benefits, such as Social Security or Medicaid. Nothing will happen to those benefits if you decide to take part or not to take part in this study.

AD003. (HH_MEMBER) Are you a member of this household (and at least [LOCAL AGE OF MAJORITY])?

YES…………………………………………………………………………………………1

NO…………………………………………………………………………………………..2

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: IF RESPONSE IS NOT ‘YES’ ASK TO SPEAK WITH AN ADULT HOUSEHOLD MEMBER AND RE-READ INTRODUCTION

• OUTCOME 1- IF NO ONE HOME OF LOCAL AGE OF MAJORITY OR OLDER, SAY

”Thank you for your time. When would be the best time to reach someone who lives here who is [LOCAL AGE OF MAJORITY] or older? “

LEAVE COPY OF STUDY BROCHURE AND RECORD CONTACT INFORMATION IN CASE MANAGEMENT SYSTEM. DISPOSITION CASE APPROPRIATELY AND PLAN STRATEGY FOR LATER FOLLOW-UP

• OUTCOME 2- NO ONE [LOCAL AGE OF MAJORITY] OR OLDER LIVES IN THE DWELLING UNIT; LEAVE STUDY BROCHURE AND RECORD CONTACT INFORMATION IN CASE MANAGEMENT SYSTEM

• OTHER REFUSED OR DON’T KNOW RESPONSE: LEAVE STUDY BROCHURE AND RECORD CONTACT INFORMATION IN CASE MANAGEMENT SYSTEM

General Eligibility Questions

(TIME_STAMP_2). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

GE001. First, I’d like to make sure I have the correct address. Just to confirm, what is the address of this household?

PROGRAMMER INSTRUCTION: DISPLAY ADDRESS AS KNOWN; ALLOW INTERVIEWER TO MAKE CORRECTIONS

INTERVIEWER INSTRUCTION: CONFIRM ADDRESS IF R PREVIOUSLY STATED IT.

ADDRESS 1 (ADDRESS_1)

• STREET NUMBER

• PRE-DIRECTIONAL

• STREET NAME

• STREET TYPE

• POST DIRECTIONAL

ADDRESS 2 (ADDRESS_2)

UNIT (UNIT)

• UNIT TYPE

• UNIT NUMBER

CITY (CITY)

STATE (STATE)

ZIP CODE (ZIP)

ZIP+4 (ZIP4)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: THIS QUESTION REFERS TO THE RESPONDENT’S HOME ADDRESS AND IS USED TO CONFIRM ELIGIBILITY.

• INTERVIEWERS MUST CHECK RESPONDENT’S ADDRESS AGAINST LISTING OF ELIGIBLE ADDRESSES. IF ADDRESS IS NOT ON LIST, CASE SHOULD BE DISPOSITIONED AS INELIGIBLE.

• IF THE RESPONDENT REFUSES TO ANSWER THE ADDRESS QUESTION, DESCRIBE HOW HIS/HER ELIGIBILITY IS DETERMINED BY HIS/HER RESIDENTIAL ADDRESS AND THAT ALL DATA ARE KEPT CONFIDENTIAL AND SECURE. IF RESPONDENT STILL REFUSES, END THE INTERVIEW AND CODE AS A REFUSAL AND COMPLETE A NON-INTERVIEW REPORT.

• IF RESPONSE IS ‘DON’T KNOW’, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.

• IF THE RESPONDENT DOES NOT LIVE AT THIS ADDRESS, CHECK TO SEE IF S/HE LIVES AT AN ELIGIBLE ADDRESS. IF SO, SELECT CORRECT ADDRESS AND ADMINISTER QUESTIONNAIRE FOR THAT ADDRESS. IF ADDRESS IS NOT AN ELIGIBLE DWELLING UNIT, DO NOT COMPLETE THE REST OF THE QUESTIONNAIRE AND END THE INTERVIEW. THANK RESPONDENT FOR HIS/HER TIME.

PROGRAMMER INSTRUCTIONS:

• IF SUFFICIENT ADDRESS INFORMATION IS PROVIDED GO TO (DU_ELIG_CONFIRM) AND SET VALUE AS APPROPRIATE

• IF RESPONDENT REFUSES TO PROVIDE ADDRESS INFORMATION GO TO

(DU_ELIG_CONFIRM) AND SET AS UNKNOWN

(DU_ELIG_CONFIRM) FLAG TO NOTE ADDRESS ELIGIBILITY

ELIGIBLE DWELLING UNIT 1

INELIGIBLE DWELLING UNIT 2

DWELLING UNIT ELIGIBILITY IS UNKNOWN 3

GE002. (PRIVATE) Is this a private residence?

INTERVIEWER INSTRUCTIONS: DO NOT CONSIDER GROUP QUARTERS TO BE A PRIVATE RESIDENCE.

YES 1 (TIME_STAMP_4)

NO 2

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_3). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

GE003. (PLACE_TYPE) What type of place is this?

SENIOR LIVING……………………………………..1 (TIME_STAMP_10); SET (HH_ELIG) = 4

MILITARY BARRACKS…………………………….2 (TIME_STAMP_10); SET (HH_ELIG) = 4

RELIGIOUS QUARTERS…………………………..3 (TIME_STAMP_10); SET (HH_ELIG) = 4

ON-CAMPUS STUDENT HOUSING……………..4 (TIME_STAMP_10); SET (HH_ELIG) = 4

CORRECTIONAL FACILITY……………………….5 (TIME_STAMP_10); SET (HH_ELIG) = 4

HOMELESS SHELTER……………………………………………………………………….6

GROUP HOME FOR MENTALLY ILL/DEVELOPMENTALLY DISABLED……………..7

JOB CORPS HOUSING………………………………………………………………………8

DOMESTIC VIOLENCE SHELTER………………………………………………………….9

HALFWAY HOUSE…………………………………………………………………………...10

PRIVATE RESIDENCE…………………………………………………….11 (TIME_STAMP_4)

OTHER…………………………………………………………………..-5 (PLACE_TYPE_OTH)

REFUSED…………………………………………………………………………………….. -1

DON’T KNOW……………………………………………………………………………………-2

GE003A. (PLACE_TYPE_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

GE004. (PLACE_NAME) What is the name of this place?

INTERVIEWER INSTRUCTION: CONFIRM SPELLING.

____________________________________________________________

NAME OF GROUP LIVING QUARTERS

REFUSED -1

DON’T KNOW -2

GE005. (ADMIN) Since this building has group living quarters, I will need to talk to a manager or administrator. Is a manager or administrator available to speak with me now?

YES 1(ROOMS)

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: WHEN CASE IS CONTINUED WITH A MANAGER OR ADMINISTRATOR, BEGIN WITH INTRODUCTION AND CONSENT AND THEN SKIP TO QUESTION GE006 (ROOMS)

OTHERWISE SAY “ Thank you for your time. When would be a good time to come back to speak with the manager or administrator?” RECORD TIME AND DAYS MANAGER OR ADMINISTRATOR AVAILABLE AND SKIP TO (TIME_STAMP_11)

GE006. (ROOMS) [SPEAKING TO A BUILDING MANAGER] Are there any rooms at this address set aside for staff that would be considered their permanent residence?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

GE007. (RESIDE_AGE) Can female residents [or staff] between the ages of [LOCAL AGE OF MAJORITY] and 49 live here?

PROGRAMMER INSTRUCTIONS: IF (ROOMS) = YES, THEN FILL QUESTION TEXT WITH “or staff.”

YES 1 (RESIDE_PREG)

NO 2 (TIME_STAMP_10); SET (HH_ELIG) = 4

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

GE008. (RESIDE_PREG) Can pregnant women [including staff] living here have a baby and continue to live here?

PROGRAMMER INSTRUCTIONS: IF (ROOMS) = YES, THEN FILL QUESTION TEXT WITH “including staff.”

YES 1

NO 2 (TIME_STAMP_10); SET (HH_ELIG) = 4

REFUSED -1

DON’T KNOW -2

Household Roster

(TIME_STAMP_4). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HR001. (R_GENDER) IS RESPONDENT MALE OR FEMALE?

INTERVIEWER INSTRUCTION: SELECT BY OBSERVATION.

MALE 1

FEMALE 2

BOTH 3

DON’T KNOW -2

HR002. (NUM_ADULT) (Including yourself,) what is the total number of adults age [LOCAL AGE OF MAJORITY] or older who live here?

[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.]

|___|___|

NUMBER OF ADULTS IN HOUSEHOLD

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF RESPONSE > 10; PROMPT INTERVIEWER TO CONFIRM

INTERVIEWER INSTRUCTION:

• IF NONRESPONSE ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER

• IF RESPONSE = 0; LEAVE STUDY BROCHURE AND RECORD CONTACT INFORMATION IN CASE MANAGEMENT SYSTEM

HR003. (NUM_MALE) [Including yourself], how/How) many men [LOCAL AGE OF MAJORITY] or older live here?

|___|___|

NUMBER OF ADULT MALES

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF (R_GENDER) = MALE, INCLUDE TEXT IN BRACKETS

• INCLUDE SOFT EDIT IF RESPONSE > 10; PROMPT INTERVIEWER TO CONFIRM

HR004. (NUM_FEMALE) [Including yourself, how/How] many women [LOCAL AGE OF MAJORITY] or older live here?

|___|___|

NUMBER OF ADULT FEMALES

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF (R_GENDER) = FEMALE, INCLUDE TEXT IN PARENTHESES

• INCLUDE SOFT EDIT IF RESPONSE > 10; PROMPT INTERVIEWER TO CONFIRM

PROGRAMMER INSTRUCTIONS: SUM OF (NUM_MALE) AND (NUM_FEMALE) SHOULD BE EQUAL TO (NUM_ADULT); IF EDIT CHECK FAILS, DISPLAY ERROR MESSAGE “NUMBER OF ADULT MALES PLUS THE NUMBER OF ADULT FEMALES SHOULD EQUAL THE NUMBER OF ADULTS IN THE HOSUEHOLD. ATTEMPT TO CONFIRM INFORMATION.”

HR006. (HH_AGE_ELIG) This study is looking at children’s health, including development before birth. We are interested in women between [LOCAL AGE OF MAJORITY] and 49. Thinking only about women ages [LOCAL AGE OF MAJORITY] to 49, [including yourself], how many women [LOCAL AGE OF MAJORITY] to 49 live here?

INTERVIEWER INSTRUCTION: IF RESPONSE IS REFUSED/DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER

PROGRAMMER INSTRUCTIONS: IF (HR001) (R_GENDER) = FEMALE INSERT “including yourself”

|___|___|

NUMBER OF WOMEN [LOCAL AGE OF MAJORITY] - 49

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• INCLUDE SOFT EDIT IF (HH_AGE_ELIG) > 10

• INCLUDE HARD EDIT IF (HH_AGE_ELIG) > (NUM_FEMALE)

BASED ON RESPONSE, SET (NUM_AGE_ELIG) = TOTAL NUMBER OF WOMEN IN HH AGES [LOCAL AGE OF MAJORITY] – 49

(TIME_STAMP_5). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HR005. (PREGNANT_HH) Is anyone living in the household currently pregnant?

YES 1

NO 2 (TIME_STAMP_6)

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW -2 (TIME_STAMP_6)

HR007. (NUM_PREG) How many women currently living here are pregnant?

PROGRAMMER INSTRUCTION: ASK IF (PREGNANT_HH) = YES

|___|___|

NUMBER OF PREGNANT WOMEN

NO ONE IN HOUSEHOLD IS PREGNANT…………………………………..1(TIME_STAMP_6)

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• INCLUDE SOFT EDIT IF (NUM_PREG) > 5

PROGRAMMER INSTRUCTIONS:

• LOOP THROUGH QUESTIONS HR008 (P_AGE), HR009 (P_FNAME), HR010 (P_RELATE) FOR THE TOTAL NUMBER OF WOMEN IDENTIFIED IN HR007 (NUM_PREG)

HR008. (P_AGE)

IF (NUM_PREG) = 1

I have a few more questions about [you/her]. This information will help us to determine whether [you/she] may be able to take part in the National Children’s Study. Thinking about the oldest pregnant woman living in the household, how old [is she/are you]? If you are unsure, please make your best guess.

IF (NUM_PREG) > 1 AND FIRST LOOP CYCLE

I have a few more questions about them. This information will help us to determine whether they may be able to take part in the National Children’s Study. Thinking about the oldest pregnant woman living in the household, how old [is she/are you]? If you are unsure, please make your best guess.

IF (NUM_PREG) > 1 AND SUBSEQUENT LOOP CYCLE

Thinking about the oldest pregnant woman living in the household, how old [is she/are you]?

|___|___|

AGE

NO ONE IN HOUSEHOLD IS PREGNANT…………………………………..1(TIME_STAMP_6)

REFUSED -1

DON’T KNOW -2

HR009. (P_FNAME) What is [her/your] first name?

INTERVIEWER INSTRUCTION: CONFIRM SPELLING.

____________________________________________________________

FIRST NAME

REFUSED -1

DON’T KNOW -2

HR010. (P_RELATE) How is she related to you?

INTERVIEWER INSTRUCTION: IF YOU ARE CERTAIN THE RESPONDENT IS SPEAKING ABOUT HERSELF, SELECT ‘SELF’ AND DO NOT READ THIS QUESTION.

SELF 1

WIFE 2

DAUGHTER 3

GRAND-DAUGHTER 4

MOTHER 5

GRAND-MOTHER 6

SISTER 7

PARTNER 8

ROOMMATE 9

OTHER RELATIVE 10

OTHER NON-RELATIVE 11

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: AFTER ALL LOOPS ARE COMPLETED

• CREATE VARIABLE TO CAPTURE THE TOTAL NUMBER OF PREGNANT WOMEN IN HOUSEHOLD WHERE (NUM_PREG) = TOTAL NUMBER OF PREGNANT WOMEN; REGARDLESS OF AGE-ELIGIBILITY AND IF THEY CAN PARITICPATE IN THE NCS

• CREATE VARIABLE TO COUNT THE PREGNANT WOMEN IN HOUSEHOLD STRATIFIED BY AGE WHERE

  • NUM_PREG_ADULT = NUMBER OF PREGNANT WOMEN AT LOCAL AGE OF MAJORITY OR OLDER

  • NUM_PREG_MINOR = NUMBER OF PREGNANT WOMEN YOUNGER THAN AGE OF MAJORITY

(TIME_STAMP_6). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS: CREATE NEW FLAG TO CALCULATE THE NUMBER OF OTHER AGE-ELIGIBLE WOMEN IN HOUSEHOLD ON WHO WE NEED TO COLLECT INFORMATION WHERE

NUM_AGE_LOOP = (NUM_AGE_ELIG) - (NUM_PREG_ADULT)

LOOP THROUGH QUESTIONS HR011/(AGE_ELIG_FNAME), HR012/(AGE_ELIG_AGE), AND HR013/(AGE_ELIG_RELATE) FOR THE TOTAL NUMBER OF WOMEN CALCULATED IN NUM_LOOP

HR011. (AGE_ELIG_FNAME) Please think about the other women in your household who are between ages [LOCAL AGE OF MAJORITY] and 49 and who we haven’t already talked about. [Let’s start with the oldest…/Thinking about the next oldest…].

What is [her/your] first name?

INTERVIEWER INSTRUCTION: CONFIRM SPELLING.

____________________________________________________________

FIRST NAME

REFUSED -1

DON’T KNOW -2

HR012. (AGE_ELIG_AGE) How old [is she/are you]?

|___|___|

AGE

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: IF AGE < LOCAL AGE OF MAJORITY OR > 49 DISPLAY ERROR MESSAGE; IF CORRECT VALUE IS OUTSIDE OF ELIGIBILE AGE RANGE, UPDATE (NUM_AGE_ELIG) AS APPROPRIATE

INTERVIEWER INSTRUCTIONS: CONFIRM CORRECT AGE AND ENTER.

HR013. (AGE_ELIG_RELATE) How is she related to you?

INTERVIEWER INSTRUCTION: IF YOU ARE CERTAIN THE RESPONDENT IS SPEAKING ABOUT HERSELF, SELECT ‘SELF’ AND DO NOT READ THIS QUESTION.

SELF 1

WIFE 2

DAUGHTER 3

GRAND-DAUGHTER 4

MOTHER 5

GRAND-MOTHER 6

SISTER 7

PARTNER 8

ROOMMATE 9

OTHER RELATIVE 10

OTHER NON-RELATIVE 11

REFUSED -1

DON’T KNOW -2

Summary of Women in HousEHOld

(TIME_STAMP_7). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS: UPDATE VARIABLES

• NUM_PREG = TOTAL NUMBER OF PREGNANT WOMEN.

• NUM_PREG_ADULT = NUMBER OF PREGNANT WOMEN [LOCAL AGE OF MAJORITY] OR OLDER

• NUM_PREG_MINOR = NUMBER OF PREGNANT WOMEN YOUNGER THAN AGE OF MAJORITY

• NUM_AGE_ELIG = TOTAL NUMBER OF WOMEN IN HOUSEHOLD AGES [LOCAL AGE OF MAJORITY] - 49

DISPLAY THE NAMES, AGES, AND PREGNANCY STATUS OF WOMEN IN THE POTENTIALLY ELIGIBLE CATEGORIES (NUM_PREG_ADULT) AND (NUM_AGE_ELIG). PREGNANT WOMEN WHO ARE YOUNGER THAN THE AGE OF MAJORITY ARE NOT ELIGIBILE TO PARTICIPATE IN THE NCS AND CANNOT BE ADMINISTERED A PREGNANCY SCREENER.

WO001. Thank you. I have recorded that there are [NUMBER] women in the household who may be able to participate in the Study.

THE TOTAL NUMBER OF NCS ELIGIBLE WOMEN SHOULD BE FILLED INTO TEXT ABOVE

INTERVIEWER INSTRUCTION: READ NAMES AND CONFIRM LISTING WITH RESPONDENT

WO002. (CONFIRM_1) This number should include all women who are age [LOCAL AGE OF MAJORITY] to 49, or are currently pregnant and older than [LOCAL AGE OF MAJORITY], who usually live here, even those who may be temporarily away, such as on business, on vacation, on active military duty, in a hospital or in school. Is this correct?

YES, ALL INFORMATION IS CORRECT…………………………………… 1

NO, THERE ARE ERRORS IN THE LISTING……………………………… 2 (CONFIRM_2)

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• ALLOW INTERVIEWER TO EDIT EACH RECORD TO CORRECT THE NAME, AGE, PREGNANCY STATUS, AND RELATIONSHIP FOR EACH IDENTIFIED WOMAN

• ALLOW INTERVIEWER TO DELETE RECORDS ENTERED IN ERROR

• ALLOW INTERVIEWER TO ADD RECORDS MISSED ORIGIANLLY

• WHEN COMPLETE, DISPLAY CORRECTED LISTING AND CONFIRM IN WO003/(CONFIRM_2) BELOW.

INTERVIEWER INSTRUCTION: READ NAMES AND CONFIRM WITH RESPONDENT AGAIN

WO003. (CONFIRM_2) Is this [LISTING] correct?

YES, ALL INFORMATION IS CORRECT…………………………………… 1

NO, THERE ARE ERRORS IN THE LISTING……………………………… 2

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: MAKE FURTHER CORRECTIONS UNTIL COMPLETE AND ACCURATE THEN UPDATE VARIABLES AS REQUIRED:

• NUM_PREG = TOTAL NUMBER OF PREGNANT WOMEN.

• NUM_PREG_ADULT = NUMBER OF PREGNANT WOMEN [LOCAL AGE OF MAJORITY] OR OLDER

• NUM_PREG_MINOR = NUMBER OF PREGNANT WOMEN YOUNGER THAN AGE OF MAJORITY

• NUM_AGE_ELIG = TOTAL NUMBER OF WOMEN IN HOUSEHOLD AGES [LOCAL AGE OF MAJORITY] - 49

SET (HH_ELIG) BASED ON UPDATES

(HH_ELIG = 1) HOUSEHOLD INFORMANT IS ELIGIBLE FOR PREGNANCY SCREENER

• IF RESPONDENT/HOUSEHOLD INFORMANT IS AGE-ELIGIBLE OR PREGNANT AND OVER THE LOCAL AGE OF MAJORITY; SET (HH_ELIG) = 1

(HH_ELIG = 2) ONE OR MORE WOMEN IN HOUSEHOLD ARE ELIGIBLE FOR PREGNANCY SCREENER

• EXCLUDING RESPONDENT/HOUSEHOLD INFORMANT- IF (NUM_PREG_ADULT) > 1 OR (NUM_AGE_ELIG) > 1; SET (HH_ELIG) = 2

(HH_ELIG = 3) NO CURRENT HOUSEHOLD MEMBERS ARE ELIGIBLE FOR PREGNANCY SCREENER

• EXCLUDING RESPONDENT/HOUSEHOLD INFORMANT- IF (NUM_PREG_ADULT) < 1 AND (NUM_AGE_ELIG) < 1; SET (HH_ELIG) = 3

Hidden Dwelling Units

(TIME_STAMP_8). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTION: ASK SECTION ONLY IF (PRIVATE = YES) OR (PLACE_TYPE = PRIVATE RESIDENCE); ELSE GO TO (TIME_STAMP_9)

HD001. (RESIDENCE_TYPE). IS THIS BUILDING A…

INTERVIEWER ANSWERED: SELECT BY OBSERVATION. IF UNSURE SELECT SINGLE-FAMILY HOME.

SINGLE-FAMILY HOME…………………………………………… 1

MULTI UNIT/APARTMENT ……………………………………… 2 (ENUM_STATUS)

GROUP QUARTERS ………………………………………………. 3 (TIME_STAMP_9)

HD002. (APT_1). I want to be sure that every household in this area has been given a chance to participate in this important study. Are there any other living quarters here such as an attic or basement apartment?

YES 1

NO 2 (TIME_STAMP_9)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

HD003. (APT_2) Where is this unit located?

LOCATION COLLECTED………………………………………………….1(HIDDEN_DU_ADDR)

REFUSED -1

DON’T KNOW -2

(HIDDEN_DU_ADDR) Would you please tell me the address of that unit?

INTERVIEWER INSTRUCTION: RECORD AS MUCH INFORMATION AS POSSIBLE ABOUT HIDDEN DWELLING UNIT ADDRESS; IF MULTIPLE HIDDEN DUS EXIST, LOOP THROUGH EACH ONE

PROBE: “Are there any others?”

ADDRESS 1 (HDU_ADDRESS_1)

• STREET NUMBER

• PRE-DIRECTIONAL

• STREET NAME

• STREET TYPE

• POST DIRECTIONAL

ADDRESS 2 (HDU_ADDRESS_2)

UNIT (HDU_UNIT)

• UNIT TYPE

• UNIT NUMBER

CITY (HDU_CITY)

STATE (HDU_STATE)

ZIP CODE (HDU_ZIP)

ZIP+4 (HDU_ZIP4)

REFUSED -1

DON’T KNOW -2

HD004.(ENUM_STATUS)

[INTERVIEWER ANSWERED]: IS THIS THE FIRST UNIT ENUMERATED IN THE BUILDING?

YES………………………………………………………………………………….1 NO…………………………………………………………………………………...2

IF (ENUM_STATUS) = YES, FLAG CASE FOR FURTHER FOLLOW-UP TO DETERMINE IF HIDDEN DWELLING UNITS EXIST

Tracing QUESTIONS

(TIME_STAMP_9). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TR001. I have a few more questions for you. All of your information is kept completely confidential. Would you please tell me your name?

INTERVIEWER INSTRUCTION: CONFIRM FIRST NAME IF KNOWN. IF RESPONDENT IS UNWILLING TO PROVIDE INFORMATION, ASK FOR INITIALS

_____________________ ___________________

FIRST NAME LAST NAME

(R_FNAME) (R_LNAME)

REFUSED -1

DON’T KNOW -2

TR002. (PHONE_NBR) What is the best phone number to reach you?

|__|__|__| |__|__|__| -- |__|__|__|__| (PHONE_TYPE)

ENTER PHONE NUMBER AND CONFIRM.

RESPONDENT HAS NO TELEPHONE………………………………1 (TIME_STAMP_10)

REFUSED ……………………………………………………………....-1 (TIME_STAMP_10) DON’T KNOW………………………………………………………… -2 (TIME_STAMP_10)

INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS THEY HAVE NO TELEPHONE, ASK AT WHAT NUMBER THEY RECEIVE TELEPHONE CALLS

TR003. (PHONE_TYPE) Is this your home, work, cell, or another phone number?

HOME 1

WORK 2

CELL 3

FRIEND/RELATIVE 4

OTHER -5 (PHONE_TYPE_OTH)

REFUSED -1

DON’T KNOW -2

TR003A. (PHONE_TYPE_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

tr120. (PHONE_ALT) Is there an alternate phone number to reach you?

|__|__|__| |__|__|__| -- |__|__|__|__| (PHONE_ALT_TYPE)

ENTER PHONE NUMBER AND CONFIRM.

RESPONDENT HAS NO OTHER TELEPHONE…………………… 1 (TIME_STAMP_10)

REFUSED ……………………………………………………………....-1 (TIME_STAMP_10) DON’T KNOW………………………………………………………… -2 (TIME_STAMP_10)

TR121. (PHONE_ALT_TYPE) Is this your home, work, cell, or another phone number?

HOME 1

WORK 2

CELL 3

FRIEND/RELATIVE 4

OTHER -5 (PHONE_ALT_TYPE_OTH)

REFUSED -1

DON’T KNOW -2

TR121A. (PHONE_ALT_TYPE_OTH):

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

Summary of Eligibility Status

(TIME_STAMP_10). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTION: DISPLAY FINAL LISTING OF ALL WOMEN ELIGIBLE TO BE ADMINISTERED THE PREGNANCY SCREENER.

INTERVIEWER INSTRUCTION: BASED ON FINAL LISTING, USE THE FOLLOWING CLOSING STATEMENTS AND DISPOSITION CASE AS APPROPRIATE.

ES001/(HH_ELIG): ELIGIBILITY CLOSING STATEMENT AND STATUS OF CASE

PROGRAMMER INSTRUCTION: AFTER DISPLAYING APPROPRIATE CLOSING SCRIPT GO TO (TIME_STAMP_11)

(HH_ELIG = 1)- HOUSEHOLD INFORMANT IS ELIGIBLE FOR PREGNANCY SCREENER

ES001A. Thank you. It looks like you may be able to take part in this Study. To find out, I need to ask you a few more questions. This should only take about 20 minutes.

INTERVIEWER INSTRUCTION: BEGIN ADMINISTRATION OF PREGNANCY SCREENER

(HH_ELIG = 2) - ONE OR MORE WOMEN IN HOUSEHOLD ARE ELIGIBLE FOR PREGNANCY SCREENER

ES001B. Thank you. It looks like some women in this household may be able to take part in this Study. May I speak to... [NAMES OF AGE-ELIGIBLE IDENTIFIED WOMEN]?

INTERVIEWER INSTRUCTION: ATTEMPT TO COMPLETE PREGNANCY SCREENER OR SET APPOINTMENTS WITH IDENTIFIED WOMEN

(HH_ELIG = 3) - NO CURRENT HOUSEHOLD MEMBERS ARE ELIGIBLE FOR PREGNANCY SCREENER

ES001C. Thank you for taking the time to answer these questions. Right now, there is no one here that can take part in the study. Because your address is in the study area, we may be back in touch at a later time to update your household information. Thank you for your time.

(HH_ELIG = 4) - DWELLING UNIT IS NOT ELIGIBLE

ES001D. Thank you for your time. There is no one here that can take part in the study.

Interviewer-Completed Questions

(TIME_STAMP_11). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IN001. (CONTACT_TYPE) IN WHAT MODE WAS THE QUESTIONNAIRE ADMINISTERED?

IN-PERSON 1

TELEPHONE 2

MAIL 3

WEB 4

OTHER -5 (CONTACT_TYPE_OTH)

(CONTACT_TYPE_OTH):

SPECIFY _____________________________

IN002. (ENGLISH) WAS THIS DATA COLLECTION SESSION CONDUCTED IN ENGLISH?

YES 1 (INTERPRET)

NO 2 (CONTACT_LANG)

IN003. (CONTACT_LANG) WHAT OTHER LANGUAGE WAS USED TO CONDUCT THIS SESSION?

SPANISH 1 (INTERPRET)

ARABIC 2 (INTERPRET)

CHINESE 3 (INTERPRET)

FRENCH 4 (INTERPRET)

FRENCH CREOLE 5 (INTERPRET)

GERMAN 6 (INTERPRET)

ITALIAN 7 (INTERPRET)

KOREAN 8 (INTERPRET)

POLISH 9 (INTERPRET)

RUSSIAN 10 (INTERPRET)

TAGALOG 11 (INTERPRET)

VIETNAMESE 12 (INTERPRET)

URDU 13 (INTERPRET)

PUNJABI 14 (INTERPRET)

BENGALI 15 (INTERPRET)

FARSI 16 (INTERPRET)

OTHER -5 (CONTACT_LANG_OTH)

IN003A. (CONTACT_LANG_OTH):

SPECIFY _____________________________

IN004. (INTERPRET) WAS AN INTERPRETER USED?

YES 1 (CONTACT_INTERPRET)

NO 2 (TIME_STAMP_12)

IN005. (CONTACT_INTERPRET) WHAT TYPE OF INTERPRETER WAS USED?

BILINGUAL INTERVIEWER 1

IN-PERSON PROFESSIONAL INTERPRETER 2

IN-PERSON FAMILY MEMBER INTERPRETER 3

LANGUAGE-LINE INTERPRETER 4

VIDEO INTERPRETER 5

SIGN LANGUAGE INTERPRETER 6

OTHER -5 (CONTACT_INTERPRET_OTH)

IN005A. (CONTACT_INTERPRET_OTH):

SPECIFY _____________________________

(TIME_STAMP_12). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.