Form 5.1 Survey

OMB #: 0925-0593

Expiration Date: xx/xxxx

JULY LAUNCH VERSION

VERSION 7/14/2010

ASSUME PRE-PREGNANCY VISIT WAS

ADMINISTERED UNLESS NOTED

Recruitment Strategy Substudy

Enhanced Household,

Provider-Based & Two-Tier Groups

Pregnancy Probability Group Follow Up

Mailed Self-Administered Questionnaire

• Note: A formatted version of this PAPI is currently available. However, the revised OMB number needs to be inserted prior to use.

TABLE OF CONTENTS

MAILED SAQ

1. PREGNANCY SCREENER

2. TRACING QUESTIONS

DOCUMENT HISTORY

DATE	VERSION	SUMMARY OF CHANGE/MILESTONE
5/20/2010	SAQ_v1	Schoendorf draft with Graber’s programming and operational content
5/21/2010	20100521	Formatted for OMB
5/24/2010	20100521	INFORMAL SUBMISSION TO OMB
5/26/2010	20100526	INCORPORATE COMMENTS FROM OMB (no changes)
5/27/2010	20100526_jj	VARIABLE SOURCES ADDED
5/27/2010	20100527	COVER LETTER DEVELOPED BY IRB TEAM
5/28/2010	20100527	COMMENTS FROM SDSU
6/1/2010	20100601	Comments from Graber
6/3/2010	20100603	Incorporated minor changes from Program Office staff and checked for eligibility-related language
6/7/2010	20100607	Accepted changes and added comment
6/7/2010	20010607a	Incorporate changes from J. Slutsman
		COMMENTS FROM HIRSCHFELD
		RECONCILE WITH DATA ELEMENTS TABLES
6/7/2010	20010607a	FORMAL SUBMISSION TO OMB
6/10/2010	20100610	Graber comments – made consistent with OMB/IRB approved version currently in use by VCs
6/18/2010	20100618_TCA	Tracked changes accepted
6/25/2010	20100625	Integrated comments from Slutsman, Schoendorf, and Park
6/29/2010	20100629	Integrated revisions
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

Cover letter accompanying Mailed SAQ: PPG Follow Up

Date

Dear [KNOWN AGE-ELIGIBLE WOMAN],

You may remember that someone from the [INSERT NAME OF LOCAL STUDY CENTER] spoke with you about the National Children’s Study and whether you might be able to participate in the Study.

We are asking you to answer a few questions like the ones you answered before to see if anything has changed. Please take 3-5 minutes to complete the enclosed questionnaire and return it to us in the postage-paid envelope.

The National Children’s Study is the largest research study of children’s health ever conducted in the United States. We hope that you will continue to help, but it’s your choice. The information you give us will be kept private and is protected by law.

If you have questions about the Study, please visit our Web site at [INSERT LOCAL STUDY WEBSITE] or call our toll free number [INSERT LOCAL STUDY TELEPHONE NUMBER].

Thank you again for helping us learn more about the health and well-being of our nation’s children.

Sincerely,

[LOCAL PI NAME]

[LOCAL PI TITLE]

[LOCAL PI INSTITUTION]

PPG Follow-Up SAQ

MPPG001

/

(DATE)

Please enter today’s date.

__ __ / __ __/ __ __ __ __

……………………….

MPPG002

/

(PREGNANT)

M M D D Y Y Y Y

MPPG002

/

(PREGNANT)

Because we are interested in pregnancy, it is important for us to know if you’re currently pregnant. Are you pregnant now?

YES, I’M PREGNANT

……………………….

1

MPPG003

/

(PPG_DUE_DATE)

NO, I’M NOT PREGNANT

……………………….

2

MPPG004

/

(TRYING)

MPPG003

/

(PPG_DUE_DATE)

Please tell us when your baby is due.

__ __ / __ __/ __ __ __ __

……………………….

MPPG005

/

(CLOSE_1)

M M D D Y Y Y Y

I don’t know the baby’s due date

……………………….

-2

MPPG005

/

(CLOSE_1)

MPPG004

/

(TRYING)

Are you currently trying to become pregnant?

YES

……………………….

1

MPPG006

/

(CLOSE_2)

NO

……………………….

2

MPPG006

/

(CLOSE_2)

MPPG005

/

(CLOSE_1)

Thank you for answering our questions. Someone from the National Children’s Study will contact you to tell you more about the Study and possibly schedule an interview or home visit

MPPG007

/

(CONTACT)

MPPG006

/

(CLOSE_2)

Thank you for answering our questions. We’ll contact you again in a few months to ask a few more quick questions.

MPPG007

/

(CONTACT)

MPPG007

/

(CONTACT)

To help us keep in touch with you, please provide us with all of your current contact information below and let us know the best way to reach you by marking the box beside your preference.

MPPG008

/

(HOME_ADDRESS)

MPPG008

/

(HOME_ADDRESS)

Residence

MPPG009

/

(MAIL_ADDRESS)

STREET ADDRESS

CITY

STATE

ZIP

MPPG009

/

(MAIL_ADDRESS)

Mailing Address (if different)

MPPG010

/

(PHONE)

STREET ADDRESS

CITY

STATE

ZIP

MPPG010

/

(PHONE)

Please provide us with all preferred, private telephone numbers where you can be reached.

MPPG011

/

(HOME_PHONE)

MPPG011

/

(HOME_PHONE)

Home : ( _ _ _ ) _ _ _ - _ _ _ _

MPPG012

/

(WORK_PHONE)

MPPG012

/

(WORK_PHONE)

Work: ( _ _ _ ) _ _ _ - _ _ _ _

MPPG013

/

(CELL_PHONE)

MPPG013

/

(CELL_PHONE)

Cell: ( _ _ _ ) _ _ _ - _ _ _ _

MPPG014

/

(OTHER_PHONE)

MPPG014

/

(OTHER_PHONE)

Other: ( _ _ _ ) _ _ _ - _ _ _ _

MPPG015

/

(EMAIL)

MPPG015

/

(EMAIL)

Please provide us with the most private e-mail where you can be reached.

MPPG016

/

(END)

E-Mail _____________________________________

MPPG016

/

(END)

Thank you very much for completing this questionnaire. All of your responses are very important. If you have any questions, please call the toll-free number that is provided in the cover letter you received with this questionnaire. Please return this completed questionnaire in the postage-paid envelope we provided.

Public reporting burden for this collection of information is estimated to average 5 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.