Form 2.3 Survey

OMB #: 0925-0593

Expiration Date: xx/xxxx

JULY LAUNCH VERSION

VERSION 7/14/2010

Recruitment Strategy Substudy

Provider-Based CATI Pregnancy Screener

TABLE OF CONTENTS

CATI

INITIAL CONVERSATION WITH OUTGOING CALLER

VERBAL CONSENT TO SCREENING FOR STUDY ELIGIBILITY

GENERAL ELIGIBILITY QUESTIONS

FAMILIARITY WITH THE NATIONAL CHILDREN’S STUDY

PREGNANCY SCREENER

DEMOGRAPHICS

TRACING QUESTIONS

CLOSING STATEMENTS

CONCLUSION

FINAL 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 schemas is shaded. Variable names are shown in BOLD CAPS.

DOCUMENT HISTORY

DATE	VERSION	SUMMARY OF CHANGE/MILESTONE
6/3/2010	20100603	INITIAL DRAFT
6/4/2010	20100603	HIGHLIGHT ELIGIBILITY LANGUAGE – TO BE CORRECTED
6/7/2010	20100607	INCORPORATE EDITS FROM J. PARK
6/7/2010	20100607a	INCORPORATE EDITS FROM J. SLUTSMAN
6/9/2010	20100607a	FORMAL SUBMISSION TO OMB
6/14/2010	20100614	Graber comments and revisions
6/18/2010	20100618_TCA	Graber revisions and tracked changes accepted
6/25/2010	20100625	Incorporated comments from Slutsman, Schoendorf and Park
6/29/2010	20100629	Changes incorporated.
7/14/2010	20100714	Accept format changes
7/15/2010	20100714	SUBMISSION TO OMB
		INCORPORATE COMMENTS FROM OMB
		SUBMIT TO NICHD IRB
		RECONCILE WITH DATA ELEMENTS TABLES

NOTE: Italics denote anticipated development stages

cati

INITIAL CONVERSATION WITH OUTGOING CALLER

IC001/(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IC002. (FEMALE_1) Hello, my name is [DATA COLLECTOR’S NAME ]. I’m calling from the National Children’s Study. I’d like to speak with [NAME OF WOMAN IDENTIFIED BY PROVIDER]. Is she available?

YES 1 (TIME_STAMP_3)

NO 2 (BEST_TTC)/(IC003)

REFUSED -1 (BEST_TTC)/(IC003)

DON’T KNOW -2 (BEST_TTC)(/IC003)

PROGRAMMER INSTRUCTION: PRELOAD NAME OF POTENTIAL PARTICIPANT

IC003. (BEST_TTC_1)What would be a good time to reach her?

|___|___| : |___|___|

H H M M

REFUSED -1

DON’T KNOW -2

(BEST_TTC_2)

AM 1

PM 2

REFUSED -1

DON’T KNOW -2

(BEST_TTC_3)

AFTER TIME REPORTED 1

BEFORE TIME REPORTED 2

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTIONS: ENTER IN HOUR AND MINUTE VALUES; AND SELECT AM OR PM

IC004.(PHONE) Is this a good phone number to reach [NAME]?

YES 1

NO 2 (PHONE_NBR)

REFUSED -1 (PHONE_NBR)

DON’T KNOW -2 (PHONE_NBR)

PROGRAMMER INSTRUCTION: PRELOAD NAME OF POTENTIAL PARTICIPANT

IC005. (PHONE_NBR) Would you please tell me a telephone number where she can be reached?

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

REFUSED -1 DON’T KNOW -2

IC007. Thank you again for speaking with me today. Please ask her to call us at [LOCAL SC TOLL-FREE NUMBER].

(TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

INTERVIEWER INSTRUCTION: END INTERVIEW

(TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

INTERVIEWER INSTRUCITON: WHEN SPEAKING TO THE POTENTIAL PARTICIPANT IDENTIFIED BY A PROVIDER.

IC008. I’m [NAME] from the National Children’s Study. Your healthcare provider has indicated that you may be interested in participating in the National Children’s Study. I’d like to tell you a bit about the Study and see if you are able to take part. I will just need a few minutes of your time.

INTERVIEWER INSTRUCTION: IF ADDITIONAL INFORMATION IS NEEDED, SAY: The information we get from those who take part in the study may help us learn information that will improve our children’s health for years to come.

[NAME OF LOCAL ACADEMIC INSTITUTION AND NAME OF PROVIDER] are part of this important research study aimed at improving the health and well being of children.

VERBAL CONSENT TO SCREENING FOR STUDY ELIGIBILITY

IC013. I would like to ask you some questions to determine if you may be able to participate in the Study. Is this alright with you? 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.

TR003/(R_FNAME)/(R_LNAME) What is your full name?

_____________________ ___________________

FIRST NAME LAST NAME

REFUSED -1 (EL003)/ (PERSON_DOB) DON’T KNOW -2 (EL003)/ (PERSON_DOB)

INTERVIEWER INSTRUCTIONS:

• CONFIRM SPELLING.

• IF RESPONDENT REFUSES TO PROVIDE FIRST NAME, ASK FOR INITIALS

EL003/ (PERSON_DOB) What is your date of birth?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1 (EL004)/(AGE) DON’T KNOW -2 (EL004)/(AGE)

PROGRAMMER INSTRUCTION:

• INCLUDE A SOFT EDIT/WARNING IF CALCULATED AGE IS LESS THAN LOCAL AGE OF MAJORITY OR GREATER THAN 50

• FORMAT PERSON_DOB AS YYYYMMDD

• IF FULL DOB IS GIVEN CALCULATE AGE AND AGE_RANGE BASED ON RESPONSE; SKIP TO (AGE_ELIG)

• IF ONLY MONTH AND YEAR ARE PROVIDED, CALCULATE AGE AND AGE_RANGE AND SKIP TO (AGE_ELIG)

INTERVIEWER INSTRUCTION: IF UNDER LOCAL AGE OF MAJORITY OR OLDER THAN 49, NOT ELIGIBLE FOR THE STUDY, EVEN IF PREGNANT; SKIP TO (AGE_ELIG)

EL004/ (AGE) How old are you?

ENTER AGE AT LAST BIRTHDAY IN YEARS

|___|___| (AGE_ELIG)

AGE

REFUSED -1 (AGE_RANGE)

DON’T KNOW -2 (AGE_RANGE)

PROGRAMMER INSTRUCTION: INCLUDE A SOFT EDIT/WARNING IF AGE ENTERED IS LESS LOCAL AGE OF MAJORITY OR GREATER THAN 50; CALCULATE AGE_RANGE BASED ON RESPONSE

(AGE_RANGE)

Which range best describes your age? Would you say…

Less than 18 1 (AGE_ELIG)

18-24 2 (AGE_ELIG)

25-34 3 (AGE_ELIG)

35-44 4 (AGE_ELIG)

45-49 5 (AGE_ELIG)

50-64 6 (AGE_ELIG)

65 or older 7 (AGE_ELIG)

REFUSED -1 (AGE_ELIG)

DON’T KNOW -2 (AGE_ELIG)

INTERVIEWER INSTRUCTION: DESCRIBE HOW THE ANSWER TO THIS QUESTION DETERMINES HER ELIGIBILITY AND THAT ALL DATA ARE KEPT CONFIDENTIAL AND SECURE.

(AGE_ELIG)

RESPONDENT IS AGE-ELIGIBLE 1 (TIME_STAMP_4)

RESPONDENT IS YOUNGER THAN AGE OF MAJORITY 2 (TIME_STAMP_4)

RESPONDENT IS OVER AGE 49 3 (TIME_STAMP_4)

AGE ELIGIBILITY IS UNKNOWN 4 (TIME_STAMP_4)

PROGRAMMER INSTRUCTION:  BASED ON REPORTED AGE OF RESPONDENT DETERMINE WHETHER SHE IS CONSIDERED A MINOR BASED ON LOCAL REQUIREMENTS; IF RESPONDENT IS DETERMINED TO BE A MINOR, SET PPG_FIRST = 5

(TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

EL012/ (ADDRESS VARIABLES) What is your address?

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) (EL014) (DU_ELIG_CONFIRM)

REFUSED -1 (DU_ELIG_CONFIRM)

DON’T KNOW -2 (DU_ELIG_CONFIRM)

INTERVIEWER INSTRUCTIONS: IF RESPONDENT REFUSES/DON’T KNOW: DESCRIBE HOW HER ELIGIBILITY IS DETERMINED BY HER RESIDENTIAL ADDRESS AND THAT ALL DATA ARE KEPT CONFIDENTIAL AND SECURE.

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

EL014/ (DU_ELIG_CONFIRM)

RESPONDENT LIVES IN AN ELIGIBLE DWELLING UNIT 1 (TIME_STAMP_5)

RESPONDENT DOES NOT LIVE IN AN ELIGIBLE DWELLING UNIT

2 TIME_STAMP_10)

SET PPG_FIRST = 6

DWELLING UNIT ELIGIBILITY IS UNKNOWN 3 (TIME_STAMP_5)

INTERVIEWER INSTRUCTION: THIS QUESTION IS USED TO FLAG ELIGIBILITY.

FAMILIARITY WITH THE NATIONAL CHILDREN’S STUDY

FA001/(TIME_STAMP_5) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

FA002/ (KNOW_NCS) Before today, had you heard about the National Children’s Study?

YES 1 (FA003)/(HOW_KNOW_NCS)

NO 2 (ELIG)

REFUSED -1 (ELIG) DON’T KNOW -2 (ELIG)

FA003/(HOW_KNOW_NCS) How did you hear about the National Children’s Study?

INTERVIEWER INSTRUCTION: SELECT ALL THAT APPLY AND PROBE FOR ANY OTHER MEANS

ADVANCE LETTER MAILED BY NCS 1

HOUSEHOLD ENUMERATION 2

CONTINUOUS TRACKING OF DU – NEW MEMBER OF EXISTING HOUSEHOLD 3

CONTINUOUS TRACKING OF DU – NEW HOUSEHOLD 4

PRENATAL CARE PROVIDER 5

OTHER HEALTH CARE PROVIDER 6

OTHER NCS RESPONDENT 7

FRIEND 8

NEIGHBOR 9

FAMILY MEMBER 10

CO-WORKER 11

SELF/RESPONDENT REFERRAL 12

SCHOOL 13

WIC OR OTHER SOCIAL AGENCY 14

RELIGIOUS ORGANIZATION 15

COMMUNITY PARTNERS/OUTREACH EVENT 16

MEDIA: PRINT MEDIA 17

MEDIA: TV 18

MEDIA: RADIO 19

SOCIAL NETWORKING MEDIA (E.G., INTERNET, FACEBOOK, MYSPACE, BLOGS, ETC.) 20

OTHER -5 (FA008)/ (HOW_KNOW_NCS_OTH)

REFUSED -1

DON’T KNOW -2

FA008/ (HOW_KNOW_NCS_OTH)

SPECIFY ___________________________

REFUSED -1

DON’T KNOW -2

(ELIG) PROGRAMMER INSTRUCTIONS: PROGRAM SKIP PATTERNS ACCORDING TO TABLE BELOW

		DU_ELIG_CONFIRM
			1	2	3
AGE_ELIG			ELIGIBLE DWELLING UNIT	INELIGIBLE DWELLING UNIT	UNKNOWN ELIGIBILITY
	1	AGE-ELIGIBLE	TIME_STAMP_6	TIME_STAMP_6	TIME_STAMP_6
	2	YOUNGER THAN AGE OF MAJORITY	TIME_STAMP_11	TIME_STAMP_11	TIME_STAMP_11
	3	OVER AGE 49	TIME_STAMP_6	TIME_STAMP_6	TIME_STAMP_6
	4	UNKNOWN	TIME_STAMP_12	TIME_STAMP_12	TIME_STAMP_12

PREGNANCY SCREENER

PS001/(TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PS002.We are asking women of childbearing age a few questions about pregnancy. Not all women who answer these questions will be able 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. We first want to know….

PS004./(PREGNANT) IF ADULT IS KNOWN TO BE PREGNANT, ADD [Just to confirm,] Are you pregnant now?

YES 1 (PS006) (ORIG_DUE_DATE)

SET (PPG_FIRST) = 1

NO, NO ADDITIONAL INFORMATION PROVIDED 2 (PS005)

(IF VOLUNTEERED BY RESPONDENT)

NO, RECENTLY LOST PREGNANCY (MISCARRIAGE/ABORTION) 3 (DE001)(TIME_STAMP_8); SET (PPG_FIRST) = 3

NO, RECENTLY GAVE BIRTH 4

(DE001) (TIME_STAMP_8); SET (PPG_FIRST) = 4

NO, UNABLE TO HAVE CHILDREN (HYSTERECTOMY, TUBAL LIGATION) 5

(PS014)/(HYSTER)

REFUSED -1 (PS012)/(TIME_STAMP_7)

DON’T KNOW -2 (PS012)/(TIME_STAMP_7)

PS005. IF PREGNANT = NO - NO ADD’L INFO AND AGE < 50 (TIME_STAMP_7)

IF PREGNANT = NO - NO ADD’L INFO AND AGE > 50 (TIME_STAMP_8)

SET (PPG_FIRST) = 5

INTERVIEWER INSTRUCTION: IF NOT PREGNANT AND OVER 49, NOT ELIGIBLE FOR THE STUDY

PS006/(ORIG_DUE_DATE)] [Congratulations.] When is your baby due?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1 (PS008)(DATE_PERIOD)

DON’T KNOW -2 (PS008)(DATE_PERIOD)

INTERVIEWER INSTRUCTION:

• ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR

• IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE

PROGRAMMER INSTRUCTIONS:

• IF RESPONDENT PROVIDED VALID DATE IN (ORIG_DUE_DATE) SKIP TO (TIME_STAMP_8)

• CHECK REPORTED DUE DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:

  • IF DATE IS MORE THAN 9 MONTHS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 9 MONTHS FROM TODAY. RE-ENTER DATE.”

  • IF DATE IS MORE THAN 1 MONTH BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT OCCURRED MORE THAN A MONTH BEFORE TODAY. RE-ENTER DATE.”

  • IF VALID DUE DATE WAS PROVIDED, SET (ORIG_DUE_DATE) = YYYYMMDD AS REPORTED ; GO TO PS008 (DATE_PERIOD); SET (PPG_FIRST) = 1

  • IF NO VALID DATE IS GIVEN  GO TO PS008 (DATE_PERIOD)

PS008/(DATE_PERIOD) What was the first day of your last menstrual period?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

IF VALID RESPONSE PROVIDED (DE001)/(TIME_STAMP_8)

REFUSED -1 (PS009) (WEEKS_PREG)

DON’T KNOW -2 (PS009) (WEEKS_PREG)

INTERVIEWER INSTRUCTION:

• ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR

• IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE

PROGRAMMER INSTRUCTIONS:

• CHECK REPORTED MENSTRUAL DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:

  • IF DATE IS MORE THAN 10 MONTHS BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 10 MONTHS BEFORE TODAY. CONFIRM DATE. IF DATE IS CORRECT, ENTER ‘DON’T KNOW’.”

  • IF DATE IS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT HAS NOT OCCURRED YET. RE-ENTER DATE.”

  • IF VALID DATE WAS PROVIDED, CALCULATE DUE DATE FROM THE FIRST DATE OF LAST MENSTRUAL PERIOD AND SET (ORIG_DUE_DATE) (YYYYMMDD) = (DATE_PERIOD) + 280 DAYS; GO TO (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 1

  • IF NO VALID DATE IS GIVEN  GO TO PS009 (WEEKS_PREG)

PS009/(WEEKS_PREG) How many weeks pregnant are you now? If you’re not sure, please make your best guess.

|___|___|

NUMBER OF WEEKS

IF VALID RESPONSE PROVIDED (DE001)/(TIME_STAMP_8)

REFUSED -1 PS010 (MONTH_PREG)

DON’T KNOW -2 PS010 (MONTH_PREG)

INTERVIEWER INSTRUCTION:

• IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE

PROGRAMMER INSTRUCTIONS:

• REJECT RESPONSES THAT ARE EITHER < 1 WEEK OR GREATER THAN 43 WEEKS

• IF VALID RESPONSE WAS PROVIDED, CALCULATE PS006 (ORIG_DUE_DATE) (YYYYMMDD)=TODAY’S DATE + (280 DAYS – WEEKS_PREG *7); GO TO (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 1

• IF NO VALID DATE IS CALCULABLE  GO TO PS010 (MONTH_PREG)

PS010/(MONTH_PREG) How many months pregnant are you now? If you’re not sure, please make your best guess.

|___|___|

NUMBER OF MONTHS

IF VALID RESPONSE PROVIDED (DE001)/(TIME_STAMP_8)

REFUSED -1 (PS011) (TRIMESTER)

DON’T KNOW -2 (PS011) (TRIMESTER)

INTERVIEWER INSTRUCTION:

• IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE

PROGRAMMER INSTRUCTIONS:

• REJECT RESPONSES THAT ARE EITHER < 1 MONTH OR GREATER THAN 12 MONTHS

• IF VALID RESPONSE WAS PROVIDED, CALCULATE DUE DATE AS FROM NUMBER OF MONTHS PREGNANT WHERE (ORIG_DUE_DATE) (YYYYMMDD)=TODAY’S DATE + (280 DAYS –((MONTH_PREG*30) -15)); GO TO (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 1

• IF NO VALID RESPONSE IS CALCULABLE  GO TO PS011 (TRIMESTER)

PS011/(TRIMESTER) Are you currently in your First, Second, or Third trimester?

1^ST TRIMESTER (1-3 MONTHS PREGNANT) 1 (TIME_STAMP_8)

2^ND TRIMESTER (4-6 MONTHS PREGNANT) 2 (TIME_STAMP_8)

3^RD TRIMESTER (7-9 MONTHS PREGNANT) 3 (TIME_STAMP_8)

REFUSED -1 (TIME_STAMP_8)

DON’T KNOW -2 (TIME_STAMP_8)

PROGRAMMER INSTRUCTIONS: CALCULATE DUE DATE AS FROM REPORTED TRIMESTER

• 1ST TRIMESTER: ORIG_DUE_DATE = TODAY’S DATE + (280 DAYS – 46 DAYS)

• 2ND TRIMESTER: (ORIG_DUE_DATE) = TODAY’S DATE + (280 DAYS – 140 DAYS)

• 3RD TRIMESTER: (ORIG_DUE_DATE) = TODAY’S DATE + (280 DAYS – 235 DAYS)

• DON’T KNOW/REFUSED: (ORIG_DUE_DATE) = TODAY’S DATE + (280 DAYS – 140 DAYS)

• SET (ORIG_DUE_DATE) = YYYYMMDD AS CALCULATED

• SET (PPG_FIRST) = 1

(TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PS013/(TRYING) Are you currently trying to become pregnant?

YES 1 (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) =2

NO 2 (PS014)/ (HYSTER)

RECENTLY LOST PREGNANCY (MISCARRIAGE OR ABORTION) 3

(DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 3

UNABLE TO HAVE CHILDREN (HYSTERECTOMY, TUBAL LIGATION) 4

(PS014)/ (HYSTER)

REFUSED -1 (PS014)/ (HYSTER)

DON’T KNOW -2 (PS014)/ (HYSTER)

PS014/(HYSTER) Do any of the following apply to you? Have you had your uterus removed, sometimes called a hysterectomy?

YES 1 (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 5

NO 2 (PS015)/ (OVARIES)

REFUSED -1 (PS015)/ (OVARIES)

DON’T KNOW -2 (PS015)/ (OVARIES)

PS015/(OVARIES) (READ IF NECESSARY: Have you had…) both ovaries removed?

YES 1 (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 5

NO 2 (PS016)/ (TUBES_TIED)

REFUSED -1 (PS016)/ (TUBES_TIED)

DON’T KNOW -2 (PS016)/ (TUBES_TIED)

PS016/(TUBES_TIED) (READ IF NECESSARY: Have you had…) your tubes tied?

YES 1 (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 5

NO 2 (PS017)/ (MENOPAUSE)

REFUSED -1 (PS017)/ (MENOPAUSE)

DON’T KNOW -2 (PS017)/ (MENOPAUSE)

PS017/(MENOPAUSE) (READ IF NECESSARY: Have you…) stopped having your period or gone through menopause?

YES 1 (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 5

NO 2 (PS018)/ (MED_UNABLE)

REFUSED -1 (PS018)/ (MED_UNABLE)

DON’T KNOW -2 (PS018)/ (MED_UNABLE)

PS018/(MED_UNABLE) Is there any other medical reason why you believe you cannot become pregnant?

YES 1 (PS019)/ (MED_UNABLE_OTH)

NO 2 (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 4

REFUSED -1 (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 4

DON’T KNOW -2 (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 4

PS019. (MED_UNABLE_OTH)

SPECIFY ___________________

(DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 4

REFUSED -1 (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 4

DON’T KNOW -2 (DE001)/(TIME_STAMP_8); SET (PPG_FIRST) = 4

DEMOGRAPHIC QUESTIONS

DE001/ (TIME_STAMP_8) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IF PPG_FIRST = 3 (RECENT PREGNANCY LOSS)

I’m so sorry about your loss. I have some additional questions to ask if that is okay.

DE002/(MARISTAT) I’d like to ask about your marital status. Are you:

Married, 1 (DE003) /(EDUC)

Not married but living together with a partner 2 (DE003) /(EDUC)

Never been married? 3 (DE003) /(EDUC) Divorced, 4 (DE003) /(EDUC)

Separated 5 (DE003) /(EDUC)

Widowed, 6 (DE003) /(EDUC)

REFUSED -1 (DE003) /(EDUC) DON’T KNOW -2 (DE003) /(EDUC)

INTERVIEWER INSTRUCTION: RECORD THE RESPONDENT’S CURRENT MARITAL STATUS

DE003/(EDUC) What is the highest degree or level of school you have completed?

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1 (DE004) /(EMPLOY) HIGH SCHOOL DIPLOMA OR GED 2 (DE004) /(EMPLOY) SOME COLLEGE BUT NO DEGREE 3 (DE004) /(EMPLOY)

ASSOCIATE DEGREE 4 (DE004) /(EMPLOY) BACHELOR’S DEGREE (e.g., BA, BS) 5 (DE004) /(EMPLOY) POST GRADUATE DEGREE (e.g., Masters or Doctoral) 6 (DE004) /(EMPLOY)

REFUSED -1 (DE004) /(EMPLOY) DON’T KNOW -2 (DE004) /(EMPLOY)

DE004/(EMPLOY) Last week were you working full time, part time, going to school, keeping house, or something else?

WORKING FULL TIME 1 (DE005) /(ETHNICITY)

WORKING PART TIME 2 (DE005)/(ETHNICITY)

WITH A JOB, BUT NOT AT WORK BECAUSE OF TEMPORARY ILLNESS, VACATION, STRIKE 3 (DE005) /(ETHNICITY)

UNEMPLOYED/LAID OFF/LOOKING FOR WORK 4 (DE005) /(ETHNICITY)

RETIRED 5 (DE005) /(ETHNICITY)

IN SCHOOL 6 (DE005) /(ETHNICITY)

KEEPING HOUSE 7 (DE005) /(ETHNICITY)

OTHER -5 (DE004A)/ (EMPLOY_OTH)

REFUSED -1 (DE005) /(ETHNICITY)

DON’T KNOW -2 (DE005) /(ETHNICITY)

INTERVIEWER INSTRUCTIONS: PROBE AS NEEDED

DE004A. (EMPLOY_OTH)

SPECIFY _____________________________ (DE005) /(ETHNICITY)

REFUSED -1 (DE005)/(ETHNICITY)

DON’T KNOW -2 (DE005)/(ETHNICITY)

DE005/(ETHNICITY) Do you consider yourself to be Hispanic, or Latina?

YES 1 (DE006) /(RACE)

NO 2 (DE006) /(RACE)

REFUSED -1 (DE006) /(RACE)

DON’T KNOW -2 (DE006) /(RACE)

DE006/(RACE) What race do you consider yourself to be? You may select one or more.

PROBE: Anything else?

SELECT ALL THAT APPLY.

White,…………………………………………………………..1 (DE007) /(PERSON_LANG)

Black or African American, 2 (DE007) /(PERSON_LANG)

American Indian or Alaska Native, 3 (DE007) /(PERSON_LANG)

Asian, or 4 (DE007) /(PERSON_LANG)

Native Hawaiian or Other Pacific Islander? 5 (DE007) /(PERSON_LANG)

SOME OTHER RACE? -5 (DE006A)/ (RACE_OTH)

REFUSED- -1 (DE007) /(PERSON_LANG)

DON’T KNOW -2 (DE007) /(PERSON_LANG)

INTERVIEWER INSTRUCTION: CODE “OTHER” ONLY USE IF VOLUNTEERED.

DE006A. (RACE_OTH)

SPECIFY _____________________________ (DE007) /(PERSON_LANG)

REFUSED -1 (DE007) /(PERSON_LANG)

DON’T KNOW -2 (DE007) /(PERSON_LANG)

DE007/(PERSON_LANG) What is the primary language spoken in your home?

ENGLISH 1 (TIME_STAMP_9)

SPANISH 2 (TIME_STAMP_9)

ARABIC 3 (TIME_STAMP_9)

CHINESE 4 (TIME_STAMP_9)

FRENCH 5 (TIME_STAMP_9)

FRENCH CREOLE 6 (TIME_STAMP_9)

GERMAN 7 (TIME_STAMP_9)

ITALIAN 8 (TIME_STAMP_9)

KOREAN 9 (TIME_STAMP_9)

POLISH 10 (TIME_STAMP_9)

RUSSIAN 11 (TIME_STAMP_9)

TAGALOG 12 (TIME_STAMP_9)

VIETNAMESE 13 (TIME_STAMP_9)

URDU 14 (TIME_STAMP_9)

PUNJABI 15 (TIME_STAMP_9)

BENGALI 16 (TIME_STAMP_9)

FARSI 17 (TIME_STAMP_9)

OTHER -5 (DE008)/ (PERSON_LANG_OTH)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

DE008/(PERSON_LANG_OTH)

SPECIFY _____________________________ (TIME_STAMP_9)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

(TIME_STAMP_9) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

DE009. Now I’m going to ask a few questions about your income. Family income is important in analyzing the data we collect and is often used in scientific studies to compare groups of people who are similar. Please remember that all the information you provide is confidential.

Please think about your total combined family income during 2009 for all members of the family.

DE010/(HH_MEMBERS) How many household members are supported by your total combined family income?

|___|___| (NUM_CHILD)

NUMBER

REFUSED -1 (DE011) /(INCOME)

DON’T KNOW -2 (DE011) /(INCOME)

PROGRAMMER INSTRUCTION: RESPONSE MUST BE > 0; INCLUDE A SOFT EDIT IF RESPONSE IS > 15

DE010/(NUM_CHILD) How many of those people are children? Please include anyone under 18 years or anyone older than 18 years and in high school

|___|___|

NUMBER

REFUSED -1 (DE011) /(INCOME)

DON’T KNOW -2 (DE011) /(INCOME)

PROGRAMMER INSTRUCTIONS:

• INCLUDE HARD EDIT IF RESPONSE > HH_MEMBERS

• INCLUDE SOFT EDIT IF RESPONSE > 10

DE011/(INCOME_4CAT) Of these income groups, which category best represents your total combined family income during the last calendar year?

Less than $30,000 1 (TR001)/(TIME_STAMP_10)

$30,000 - $49,000 2 (TR001)/(TIME_STAMP_10) $50,000 - $99,999 3 (TR001)/(TIME_STAMP_10) $100,000 or more 4 (TR001)/(TIME_STAMP_10)

REFUSED -1 (TR001)/(TIME_STAMP_10) DON’T KNOW -2 (TR001)/(TIME_STAMP_10)

TRACING QUESTIONS

TR001/(TIME_STAMP_10) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TR002.These next few questions will help us to contact you again in the future.

TR005/(PHONE_NBR) What is the best phone number to reach you?

ENTER PHONE NUMBER AND CONFIRM.

|___|___|___| - |___|___|___| - |___|___|___|___| (PHONE_TYPE)

RESPONDENT HAS NO TELEPHONE 1 (TR006) (PHONE_NBR_OTH)

REFUSED -1 (TR009)/ (HOME_PHONE)

DON’T KNOW -2 (TR009)/ (HOME_PHONE)

TR006. (PHONE_NBR_OTH): IF RESPONDENT DOES NOT HAVE A TELEPHONE NUMBER, ASK WHERE RESPONDENT RECEIVES TELEPHONE CALLS, EVEN IF SHE DOES NOT HAVE HER OWN PHONE. ASK FOR AND RECORD THAT NUMBER

ENTER PHONE NUMBER AND CONFIRM.

|___|___|___| - |___|___|___| - |___|___|___|___| (PHONE_TYPE)

REFUSED -1 (TR009)/(HOME_PHONE)

DON’T KNOW -2 (TR009)/(HOME_PHONE)

TR007/(PHONE_TYPE) Is that your home, work, cell, or another phone number?

CONFIRM IF KNOWN.

HOME 1 (TR105)/(CELL_PHONE_1)

WORK 2 (TR009)/(HOME_PHONE)

CELL 3 (TR009)/(HOME_PHONE)

FRIEND/RELATIVE 4 (TR009)/(HOME_PHONE)

OTHER -5 (TR008)/(PHONE_TYPE_OTH)

REFUSED -1 (TR009)/(HOME_PHONE)

DON’T KNOW -2 (TR009)/(HOME_PHONE)

PROGRAMMER INSTRUCTION: IF TR007 (PHONE_TYPE) = HOME, THEN GO TO (CELL_PHONE_1).

TR008. (PHONE_TYPE_OTH)

SPECIFY _____________________________ (TR009)/(HOME_PHONE)

REFUSED -1 (TR009)/(HOME_PHONE)

DON’T KNOW -2 (TR009)/(HOME_PHONE)

TR009/(HOME_PHONE) What is your home phone number?

ENTER PHONE NUMBER AND CONFIRM.

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

NO HOME NUMBER 1 (TR010)/(CELL_PHONE_1)

REFUSED -1 (TR010)/(CELL_PHONE_1)

DON’T KNOW -2 (TR010)/(CELL_PHONE_1)

TR105/(CELL_PHONE_1). Do you have a personal cell phone?

PROGRAMMER INSTRUCTION: IF (PHONE_TYPE) = CELL, THEN GO TO (CELL_PHONE_2) AND DO NOT ASK CELL_PHONE_1

YES 1 (CELL_PHONE_2)

NO 2 (TR010)/(SAME_ADDR)

REFUSED -1 (TR010)/(SAME_ADDR)

DON’T KNOW -2 (TR010)/(SAME_ADDR)

TR106./(CELL_PHONE_2). May we use your personal cell phone to make future study appointments or for appointment reminders?

YES 1 (CELL_PHONE_3)

NO 2 (CELL_PHONE_3)

REFUSED -1 (CELL_PHONE_3)

DON’T KNOW -2 (CELL_PHONE_3)

TR107/(CELL_PHONE_3). Do you send and receive text messages on your personal cell phone?

YES ………………………………………………………1 (CELL_PHONE_4)

NO 2 (TR109)/(CELL_PHONE)

REFUSED -1 (TR109)/(CELL_PHONE)

DON’T KNOW -2 (TR109)/(CELL_PHONE)

TR108/(CELL_PHONE_4). May we send text messages to make future study appointments

or for appointment reminders?

YES 1 (TR109)/(CELL_PHONE)

NO 2 (TR109)/(CELL_PHONE)

REFUSED -1 (TR109)/(CELL_PHONE)

DON’T KNOW -2 (TR109)/(CELL_PHONE)

TR109/(CELL_PHONE).What is your personal cell phone number?

PROGRAMMER INSTRUCTION: IF (PHONE_TYPE) = CELL, THEN SKIP CELL_PHONE AND GO TO SAME_ADDR

|___|___|___| - |___|___|___| - |___|___|___|___| (TR010)/(SAME_ADDR)

PHONE NUMBER

REFUSED -1 (TR010)/(SAME_ADDR)

DON’T KNOW -2 (TR010)/(SAME_ADDR)

TR010/(SAME_ADDR) Is your mailing address the same as your street address?

YES 1 (TR012)/(HAVE_EMAIL)

NO 2 (TR011)/(MAILING ADDRESS VARIABLES)

REFUSED -1 (TR011)/(MAILING ADDRESS VARIABLES)

DON’T KNOW -2 (TR011)/(MAILING ADDRESS VARIABLES)

TR011/(MAILING ADDRESS VARIABLES) What is your mailing address?

INTERVIEWER INSTRUCTION: PROMPT AS NECESSARY TO COMPLETE INFORMATION

_____________________________________________________

(MAIL_ADDRESS1) ADDRESS 1 - STREET/PO BOX

_____________________________________________________

(MAIL_ADDRESS2) ADDRESS 2

_____________________________________________________

(MAIL_UNIT) UNIT

____________________________________________________

(MAIL_CITY) CITY

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

STATE ZIP CODE ZIP+4

(MAIL_STATE) (MAIL_ZIP) (MAIL_ZIP4)

REFUSED -1 (TR012)/(HAVE_EMAIL)

DON’T KNOW -2 (TR012)/(HAVE_EMAIL)

TR012/(HAVE_EMAIL) Do you have an email address?

YES 1 (TR013)/(EMAIL)

NO 2 TR016)/(PLAN_MOVE)

REFUSED -1 (TR016)/(PLAN_MOVE)

DON’T KNOW -2 (TR016)/(PLAN_MOVE)

TR013/(EMAIL) What is the best email address to reach you?

PROGRAMMER INSTRUCTION: SHOW EXAMPLE OF VALID EMAIL ADDRES SUCH AS [email protected]

ENTER E-MAIL ADDRESS: ___________________________________

REFUSED -1 (TR016)/(PLAN_MOVE)

DON’T KNOW -2 (TR016)/(PLAN_MOVE)

TR014/(EMAIL_TYPE) Is that your personal e-mail, work e-mail, or a family or shared e-mail

address?

PERSONAL 1 (TR016)/(PLAN_MOVE)

WORK 2 (TR016)/(PLAN_MOVE)

FAMILY/SHARED 3 (TR015)/(EMAIL_SHARE)

REFUSED -1 (TR016)/(PLAN_MOVE)

DON’T KNOW -2 (TR016)/(PLAN_MOVE)

TR015/(EMAIL_SHARE)

PROGRAMMER INSTRUCTIONS: IF RESPONDENT REPORTED A SHARED EMAIL ADDRESS IN (EMAIL_TYPE), SET (EMAIL_SHARE) AS APPROPRIATE THEN GO TO (PLAN_MOVE)

YES 1 (TR016)/(PLAN_MOVE)

NO 2 (TR016)/(PLAN_MOVE)

TR016/(PLAN_MOVE) Do you plan on moving from your present address in the next few months?

YES 1 (TR017)/ (WHERE_MOVE)

NO 2 (CS001)/(TIME_STAMP_11)

REFUSED -1 (CS001)/ (TIME_STAMP_11)

DON’T KNOW -2 (CS001)/ (TIME_STAMP_11)

TR017/(WHERE_MOVE) Do you know where you will be moving?

YES 1 (TR018)/(MOVE_INFO)

NO 1 (TR020)/(WHEN_MOVE)

REFUSED -1 (TR020)/(WHEN_MOVE)

DON’T KNOW -2 (TR020)/(WHEN_MOVE)

TR018/(MOVE_INFO) What is the address of your new home?

ADDRESS KNOWN 1 (NEW ADDRESS VARIABLES)

OUT OF THE COUNTRY 2 (TR020)/(WHEN_MOVE)

PO BOX ADDRESS ONLY 3 (NEW ADDRESS VARIABLES)

REFUSED -1 (TR020)/(WHEN_MOVE)

DON’T KNOW -2 (TR020)/(WHEN_MOVE)

TR019/(NEW ADDRESS VARIABLES) ENTER ADDRESS

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

_____________________________________________________

(NEW_ADDRESS1) ADDRESS 1 - STREET/PO BOX

_____________________________________________________

(NEW_ADDRESS2) ADDRESS 2

_____________________________________________________

(NEW_UNIT) UNIT

____________________________________________________

(NEW_CITY) CITY

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

STATE ZIP CODE ZIP+4

(NEW_STATE) (NEW_ZIP) (NEW_ZIP4)

REFUSED -1

DON’T KNOW -2

TR020/ (WHEN_MOVE) Do you know when you will be moving?

YES 1 (TR021)/(DATE_MOVE)

NO 2 (CS001) / (TIME_STAMP_11)

REFUSED -1 (CS001) / (TIME_STAMP_11)

DON’T KNOW -2 (CS001) / (TIME_STAMP_11)

TR021/(DATE_MOVE) When will you move?

MONTH: |___|___|

M M

YEAR: |___|___|___|___|

Y Y Y Y

PROGRAMMER INSTRUCTION: FORMAT DATE_MOVE AS YYYYMM

REFUSED -1 (CS001) / (TIME_STAMP_11)

DON’T KNOW -2 (CS001) / (TIME_STAMP_11)

CLOSING STATEMENTS

CS001/(TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTION:

• IF DU_ELIG_CONFIRM = 3 (UNKNOWN) AND NEW INFORMATION IS RECORDED IN MAILING ADDRESS VARIABLES OR NEW ADDRESS VARIABLES UPDATE DU_ELIG_CONFIRM TO REFLECT THIS INFORMATION

CS002/(PPG_FIRST)

PROGRAMMER INSTRUCTIONS: DISPLAY APPROPRIATE PPG ASSIGNMENT FOR RESPONDENT

PREGNANT AND ELIGIBLE 1 (CS003)

HIGH PROBABILITY –TRYING TO CONCEIVE 2 (CS004)

HIGH PROBABILITY – RECENT PREGNANCY LOSS 3 (CS005)

OTHER PROBABILITY – NOT PREGNANT AND NOT TRYING 4 (CS006)

UNABLE TO CONCEIVE, OR AGE-INELIGIBLE 5 (CS007)

INELIGIBLE DWELLING UNIT 6 (CS008)

CS003. Thank you for taking the time to answer these questions. You are able to be part of this important study because of your due date. I would like to tell you more about it and give you some information to help you decide if you would like to be part of the study.

CS004. Thank you for taking the time to answer these questions. You are able to be part of this important study because you are currently trying to become pregnant. 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.

CS005. [I’m so sorry to hear that you’ve lost your baby. I know this can be a hard time.] 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 taking the time to answer these questions.

CS006. Thank you for taking the time to answer these questions. We will contact you again in about three months to ask a few quick questions and update your household information.

CS007. Thank you for taking the time to answer these questions. Based on what you’ve told me, we will not ask you to take part in the study. Because your address is in the study area, we may be back in touch at later time to update your household information.

CS008. Thank you for taking the time to answer these questions. Based on what you’ve told me, we will not ask you to take part in the study.

CONCLUSION

C0001/(TIME_STAMP_12) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

(OTHER_FEMALE). Are there any other women in your household who are age [LOCAL AGE OF MAJORITY]-49 or pregnant?”

YES 1 (FEMALE_1)

NO 2 (FEMALE_END_1)

REFUSED -1 (FEMALE_END_1)

DON’T KNOW -2 (FEMALE_END_1)

PROGRAMMER INSTRUCTION: IF (OTHER_FEMALE) = YES; LOOP BACK TO (FEMALE_1) AND ATTEMPT TO COMPLETE ANOTHER PREGNANCY SCREENER WITH OTHER HOUSEHOLD MEMBER. REPEAT FOR EACH ELIGIBLE FEMALE

(FEMALE_END_1) Thank you again for your time.

FINAL INTERVIEWER-COMPLETED QUESTIONS

(TIME_STAMP_13) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

FI002/(ENGLISH) WAS THIS DATA COLLECTION SESSION CONDUCTED IN ENGLISH?

YES (FI005) (INTERPRET)

NO (FI003) (CONTACT_LANG)

FI003/(CONTACT_LANG) WHAT OTHER LANGUAGE WAS USED TO CONDUCT THIS SESSION?

SPANISH 1 (FI005)/(INTERPRET)

ARABIC 2 (FI005) /(INTERPRET)

CHINESE 3 (FI005) /(INTERPRET)

FRENCH 4 (FI005) /(INTERPRET)

FRENCH CREOLE 5 (FI005) /(INTERPRET)

GERMAN 6 (FI005) /(INTERPRET)

ITALIAN 7 (FI005) /(INTERPRET)

KOREAN 8 (FI005) /(INTERPRET)

POLISH 9 (FI005) /(INTERPRET)

RUSSIAN 10 (FI005) /(INTERPRET)

TAGALOG 11 (FI005) /(INTERPRET)

VIETNAMESE 12 (FI005) /(INTERPRET)

URDU 13 (FI005) /(INTERPRET)

PUNJABI 14 (FI005) /(INTERPRET)

BENGALI 15 (FI005) /(INTERPRET)

FARSI 16 (FI005) /(INTERPRET)

OTHER -5 (FI004)/(CONTACT_LANG_OTH)

FI004/(CONTACT_LANG_OTH)

SPECIFY _____________________________ (FI005)

FI005/(INTERPRET) WAS AN INTERPRETER USED?

YES 1 (FI006)/(CONTACT_INTERPRET)

NO 2 FI008)/(TIME_STAMP_14)

FI006/(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 (FI007)/(CONTACT_INTERPRET_OTH)

FI007. (CONTACT_INTERPRET_OTH)

SPECIFY _____________________________ (FI008) /(TIME_STAMP_12)

(TIME_STAMP_14) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTION:

• IF DU_ELIG_CONFIRM = 3 (UNKNOWN) AND NEW INFORMATION IS RECORDED IN MAILING ADDRESS VARIABLES OR NEW ADDRESS VARIABLES UPDATE DU_ELIG_CONFIRM TO REFLECT THIS INFORMATION

PROGRAMMER INSTRUCTION: ATTEMPT TO ENROLL WOMEN WHO ARE PREGNANT OR TRYING TO BECOME PREGNANT, AND MEET AGE AND RESIDENCE ELIGIBILITY REQUIREMENTS

IF PPG_FIRST = 1 AND AGE_ELIG = 1 OR 3 AND DU_ELIG_CONFIRM = 1

OR

IF PPG_FIRST = 2 AND AGE_ELIG = 1 AND DU_ELIG_CONFIRM = 1

 GO TO WOMEN’S INFORMED CONSENT

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.