Form 4 Survey

OMB #: 0925-0593

Expiration Date: xx/xxxx

JULY LAUNCH VERSION

VERSION 7/14/2010

Recruitment Strategy Substudy

Enhanced Household, Provider-Based

& High Intensity Groups

Pre-Pregnancy Interview

TABLE OF CONTENTS

CAPI

INTERVIEW INTRODUCTION

MEDICAL HISTORY

HEALTH INSURANCE

HOUSING CHARACTERISTICS

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS

TRACING QUESTIONS

INTERVIEW EVALUATION

DOCUMENT HISTORY

DATE	VERSION	SUMMARY OF CHANGE/MILESTONE
4/15/2010	20100401	INITIAL DRAFT BY SCHOENDORF AND TANEJA
NA	NA	COMMENTS FROM HIRSCHFELD
4/23/2010	20100422	INFORMAL SUBMISSION TO OMB
4/27/2010	20100422_jj	INCORPORATE VARIABLE SOURCES
5/20/2010	20100519.kcs	INCORPORATE COMMENTS FROM SCs
5/21/2010	Compared Document	COMPARED DOCUMENT VERSIONS 20100422 and 20100519.kcs
5/23/2010	20100521	INCORPORATE COMMENTS FROM OMB
5/25/2010	20100521	ADDITION OF VARIABLE NAMES AND OPERATIONAL INSTRUCTIONS
5/26/2010	20100521_jg	RECONCILE WITH DATA ELEMENTS TABLES
5/27/2010	20100527	REVISE INTERVIEW INTRODUCTION; RECOMMEND “na” RESPONSE CATEGORY IN ITEM EV004; REMOVED RACE/ETHNICITY QUESTIONS SINCE IN PREGNANCY SCREENER
6/4/2010	20100601	INCORPORATE COMMENTS FROM NCS PROGRAM OFFICE STAFF AND HIGHLIGHT LANGUAGE RELATED TO ELIGIBILITY
6/7/2010	20100607	INCORPORATE CHANGES FROM J. PARK
6/7/2010	20100607a	INCORPORATE CHANGES FROM J. SLUTSMAN
6/7/2010	20100607a	FORMAL SUBMISSION TO OMB
6/10/2010	20100610	Graber comments
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

CAPI

INTERVIEW INTRODUCTION

(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IN001. Thank you for agreeing to participate in the National Children’s Study. This interview will take about 20 minutes to complete. Your answers are important to us. There are no right or wrong answers, just those that help us understand your situation. During this interview, we will ask about yourself, your health, where you live, and your feelings about being a part of the National Children’s Study. You can skip over any questions or stop the interview at any time. We will keep everything that you tell us confidential.

First, we’d like to make sure we have your correct name and birth date.

IN002./(NAME _CONFIRM) Is your name [INSERT RESPONDENT NAME]_____________ ?

YES……………………………………………………… 1 (IN003)/(DOB_CONFIRM)

NO……………………………………………………………….2 (R_FNAME)(R_LNAME).

REFUSED …………………………………………… -1 (R_FNAME)(R_LNAME).

DON’T KNOW ………………………………………… -2 (R_FNAME)(R_LNAME).

PROGRAMMER INSTRUCTIONS: INSERT NAME OF RESPONDENT IF KNOWN

IN002A./ (R_FNAME) (R_LNAME) What is your full name?

_____________________ _____________________

FIRST NAME LAST NAME

(R_FNAME) (R_LNAME)

REFUSED -1 (DOB_CONFIRM)

DON’T KNOW -2 (DOB_CONFIRM)

INTERVIEWER INSTRUCTIONS:

• IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS, ASK FOR INITIALS OR SOME OTHER NAME SHE WOULD LIKE TO BE CALLED

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

IN003./(DOB_CONFIRM) Is your birth date [INSERT RESPONDENT’S DATE OF BIRTH AS MM/DD/YYYY]?

YES 1 (AGE_ELIG)

NO 2 (IN003A)/(PERSON_DOB)

REFUSED -1 (PERSON_DOB)

DON’T KNOW -2 (PERSON_DOB)

PROGRAMMER INSTRUCTION;

• PRELOAD RESPONDENT’S DOB IF KNOWN

• IF RESPONSE = YES, SET PERSON_DOB TO KNOWN VALUE

INTERVIEWER INSTRUCTIONS:

• IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB IS REQUIRED TO DETERMINE ELIGIBILITY

IN003A/(PERSON_DOB). What is your date of birth?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED …………………………………………………………………… -1 (AGE_ELIG)

DON’T KNOW -2 (AGE_ELIG)

INTERVIEWER INSTRUCTION:

• IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB IS REQUIRED TO DETERMINE ELIGIBILITY

• 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 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

(AGE_ELIG).

PROGRAMMER INSTRUCTION:  BASED ON DOB_CONFIRM OR PERSON_DOB CALCULATE AGE. USING KNOWN LOCAL AGE OF MAJORITY DETERMINE IF SHE IS ELIGIBLE (AT LEAST AGE OF MAJORITY AND LESS THAN AGE 50); SET AGE_ELIG AS APPROPRIATE

RESPONDENT IS AGE-ELIGIBLE 1 (TIME_STAMP_2)

RESPONDENT IS YOUNGER THAN AGE OF MAJORITY 2 (TIME_STAMP_12)

RESPONDENT IS OVER AGE 49 3 (TIME_STAMP_12)

AGE ELIGIBILITY IS UNKNOWN 4 (TIME_STAMP_2)

IF VALUE IS ‘REFUSED’ OR ‘DON’T KNOW’ FLAG CASE FOR SUPERVISOR REVIEW AT SC TO CONFIRM AGE ELIGIBILITY POST-INTERVIEW.

MEDICAL HISTORY

(TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

MC001A. Next, I have some general questions about your health and health care.

MC002./(HEALTH) Would you say your health in general is . . .

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

REFUSED -1

DON’T KNOW -2

MC050 /(EVER_PREG). Have you ever been pregnant? Please include live births, miscarriages, stillbirths, ectopic pregnancies, and pregnancy terminations.

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC110. The next questions are about medical conditions or health problems you might have now or may have had in the past.

MC003/(ASTHMA). Have you ever been told by a doctor or other health care provider that you had asthma?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC004/(HIGHBP). (Have you ever been told by a doctor or other health care provider that you had)…

Hypertension or high blood pressure {when you’re not pregnant}?

PROGRAMMER INSTRUCTION – IF (EVER_PREG = 2) DO NOT INCLUDE PHRASE “when you’re not pregnant”

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC005/(DIABETES_1). (Have you ever been told by a doctor or other health care provider that you had)…

High blood sugar or Diabetes {when you’re not pregnant}?

PROGRAMMER INSTRUCTION – IF (EVER_PREG = 2) DO NOT INCLUDE PHRASE “when you’re not pregnant”

YES 1 (DIABETES_2)

NO 2 (MC006) /(THYROID_1)

NEVER BEEN PREGNANT 3 (MC006) /(THYROID_1)

REFUSED -1 (MC006) /(THYROID_1)

DON’T KNOW -2 (MC006) /(THYROID_1)

MC005a /(DIABETES_2). Have you taken any medicine or received other medical treatment for diabetes in the past 12 months?

YES 1 MC005b./(DIABETES_3)

NO 2 . MC005b./(DIABETES_3)

REFUSED -1 . MC005b./(DIABETES_3)

DON’T KNOW -2 MC005b./(DIABETES_3)

MC005b./(DIABETES_3) Have you ever taken insulin?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC006/(THYROID_1). (Have you ever been told by a doctor or other health care provider that you had) Hypothyroidism, that is, an under active thyroid?

YES 1

NO 2 (CP010) /(VITAMIN)

REFUSED -1 (CP010) /(VITAMIN)

DON’T KNOW -2 (CP010) /(VITAMIN)

MC006a. /(THYROID_2). Have you taken any medicine or received other medical treatment for a thyroid problem in the past 12 months?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CP010/(VITAMIN). Do you currently take multivitamins, prenatal vitamins, folic acid, or folate?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC012A. This next question is about where you go for routine health care.

MC012/(HLTH_CARE) . What kind of place do you usually go to when you need routine or preventive care, such as a physical examination or check-up?

Clinic or health center 1

Doctor's office or Health Maintenance Organization

(HMO) 2

Hospital emergency room 3

Hospital outpatient department 4

Some other place 5

DOESN'T GO TO ONE PLACE MOST OFTEN 6

DOESN'T GET PREVENTIVE CARE ANYWHERE 7

REFUSED -1

DON'T KNOW -2

HEALTH INSURANCE

(TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HI000. Now I’m going to switch to another subject and ask about health insurance.

HI001/(INSURE). Are you currently covered by any kind of health insurance or some other kind of health care plan?

YES 1

NO 2 (TIME_STAMP_4)

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

HI002.. Now I’ll read a list of different types of insurance. Please tell me which types you currently have.

INTERVIEWER INSTRUCTIONS: RE-READ INTRODUCTORY STATEMENT AS NEEDED

(Do you currently have…)

(INS_EMPLOY) Insurance through an employer or union either through yourself or another family member?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_MEDICAID) Medicaid or any government-assistance plan for those with low incomes or a disability?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_TRICARE) TRICARE, VA, or other military health care?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_IHS) Indian Health Service?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_MEDICARE) Medicare, for people with certain disabilities?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_OTH) Any other type of health insurance or health coverage plan?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

Housing Characteristics

(TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC000. Now I’d like to find out more about your home and the area in which you live.

PROGRAMMER INSTRUCTIONS: IF HC002/(OWN_HOME) WAS ASKED DURING PREGNANCY SCREENER, THEN ASK HC001/(RECENT_MOVE).; ELSE SKIP TO (OWN_HOME)]

HC001/(RECENT_MOVE). Have you moved or changed your housing situation since we contacted you last?

YES 1 (HC002)/(OWN_HOME)

NO 2 (HC004)/(AGE_HOME)

REFUSED -1 (HC004)/(AGE_HOME)

DON’T KNOW -2 (HC004)/(AGE_HOME)

HC002.(OWN_HOME) Is your home…

Owned or being bought by you or someone in your household 1

Rented by you or someone in your household, or 2

Occupied without payment of rent? 3

SOME OTHER ARRANGEMENT -5 (OWN_HOME_OTH) REFUSED -1

DON’T KNOW -2

HC002A. (OWN_HOME_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC004/(AGE_HOME). Can you tell us, which of these categories do you think best describes when your home or building was built?

2001 TO PRESENT 1

1981 TO 2000 2

1961 TO 1980 3

1941 TO 1960 4

1940 OR BEFORE 5

REFUSED -1

DON’T KNOW -2

HC005/(LENGTH_RESIDE)/(LENGTH_RESIDE_UNIT) . How long have you lived in this home?

|___|___|

NUMBER

WEEKS 1

MONTHS 2

YEARS 3

REFUSED -1

DON’T KNOW -2

HC006. Now I’m going to ask about how your home is heated and cooled.

HC007/(MAIN_HEAT). Which of these types of heat sources best describes the main heating fuel source for your home?

ELECTRIC 1

GAS – PROPANE OR LP 2

OIL 3

WOOD 4

KEROSENE OR DIESEL 5

COAL OR COKE 6

SOLAR ENERGY 7

HEAT PUMP 8

NO HEATING SOURCE 9 (HC011) /(COOLING)

OTHER -5 (MAIN_HEAT _OTH)

REFUSED -1 (HC011) /(COOLING)

DON’T KNOW -2 (HC011) /(COOLING)

INTERVIEWER INSTRUCTION: SHOW RESPONSE OPTIONS ON CARD TO RESPONDENT.

HC007A/(MAIN_HEAT _OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC008/(HEAT2). Are there any other types of heat you use regularly during the heating season to heat your home?

PROBE: Do you have any space heaters, or any secondary method for heating your home?

SELECT ALL THAT APPLY.

ELECTRIC 1

GAS – PROPANE OR LP 2

OIL 3

WOOD 4

KEROSENE OR DIESEL 5

COAL OR COKE 6

SOLAR ENERGY 7

HEAT PUMP 8

NO OTHER HEATING SOURCE 9

OTHER -5 (HEAT2_OTH)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO RESPONDENT.

• PROBE FOR ANY OTHER RESPONSES

HC010A. (HEAT2_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC011/(COOLING). Does your home have any type of cooling or air conditioning besides fans?

YES 1

NO 2 (TIME_STAMP_5)

REFUSED -1 (TIME_STAMP_5)

DON’T KNOW -2 (TIME_STAMP_5)

HC012/(COOL) . Not including fans, which of the following kinds of cooling systems do you regularly use?

SELECT ALL THAT APPLY.

Window or wall air conditioners, 1

Central air conditioning, 2

Evaporative cooler (swamp cooler), or 3

NO COOLING OR AIR CONDITIONING REGULARLY

USED 4

Some other cooling system -5 (COOL_OTH)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: PROBE FOR ANY OTHER RESPONSES

HC012A. (COOL_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_5) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC017. Water damage is a common problem that occurs inside of many homes. Water damage includes water stains on the ceiling or walls, rotting wood, and flaking sheetrock or plaster. This damage may be from broken pipes, a leaky roof, or floods.

HC018/(WATER). In the past 12 months, have you seen any water damage inside your home?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HC019/(MOLD).. In the past 12 months, have you seen any mold or mildew on walls or other surfaces other than the shower or bathtub, inside your home?

YES 1

NO 2 (TIME_STAMP_6)

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW -2 (TIME_STAMP_6)

HC020/(ROOM_MOLD). In which rooms have you seen the mold or mildew?

PROBE: Any other rooms?

SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

RESPONDENT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5 (ROOM_MOLD_OTH)

REFUSED -1

DON’T KNOW -2

HC020A. (ROOM_MOLD_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC021. The next few questions ask about any recent additions or renovations to your home.

HC022/(RENOVATE) . In the past 12 months, have any additions been built onto your home to make it bigger or renovations or other construction been done in your home? Include only major projects. Do not count smaller projects such as painting, wallpapering, carpeting or refinishing floors.

YES 1

NO 2 (HC025)/(DECORATE)

REFUSED -1 (HC025)/(DECORATE)

DON’T KNOW -2 (HC025)/(DECORATE)

HC024/ (RENOVATE_ROOM) .Which rooms were renovated?

PROBE: Any others?

SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

RESPONDENT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5 (RENOVATE_ROOM_OTH)

REFUSED -1

DON’T KNOW -2

HC024A. (RENOVATE_ROOM_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC025/(DECORATE). In the past 12 months, were any smaller projects done in your home, such as painting, wallpapering, refinishing floors, or installing new carpet?

YES 1

NO 2 (TIME_STAMP_7)

REFUSED -1 (TIME_STAMP_7)

DON’T KNOW -2 (TIME_STAMP_7)

HC026/(DECORATE_ROOM) .. In which rooms were these smaller projects done?

PROBE: Any others?

SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

RESPONDENT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5 (DECORATE_ROOM_OTH)

REFUSED -1

DON’T KNOW -2

HC026A. (DECORATE_ROOM_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC033. Now I’d like to ask about the water in your home.

HC034/(WATER_DRINK). What water source in your home do you use most of the time for drinking:

Tap water, 1

Filtered tap water, 2

Bottled water, or 3

Some other source? -5 (WATER_DRINK_OTH)

REFUSED -1

DON’T KNOW -2

HC034A/(WATER_DRINK_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC035/(WATER_COOK). What water source in your home is used most of the time for cooking:

Tap water, 1

Filtered tap water, 2

Bottled water, or 3

Some other source? -5 (WATER_COOK _OTH)

REFUSED -1

DON’T KNOW -2

HC035A. (WATER_COOK_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS

(TIME_STAMP_8) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

OH000. Now, I’d like to ask some questions about your schooling and employment.

OH00A/(EDUC) . What is the highest degree or level of school that you have completed?

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1

HIGH SCHOOL DIPLOMA OR GED 2

SOME COLLEGE BUT NO DEGREE 3

ASSOCIATE DEGREE 4

BACHELOR’S DEGREE (e.g., BA, BS) 5

POST GRADUATE DEGREE (e.g., Masters or Doctoral) 6

REFUSED -1

DON’T KNOW -2

OH001/(WORKING) . Are you currently working at any full or part time jobs?

YES 1

NO 2 (TIME_STAMP_9)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

OH002a/(HOURS). Approximately how many hours each week are you working?

|___|___|___|

NUMBER OF HOURS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: INCLUDE A SOFT EDIT IF RESPONSE > 60

OH002b/(SHIFT_WORK) . Do you work a shift that starts after 2 pm?

YES 1

NO 2

SOMETIMES 3

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_9) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

DE004A. The next questions may be similar to those asked the last time we contacted you, but we are asking them again because sometimes the answers change.

DE004/(MARISTAT). I’d like to ask about your marital status. Are you:

Married, 1

Not married but living together with a partner 2

Never been married, 3 (TIME_STAMP_10)

Divorced, 4 (TIME_STAMP_10)

Separated, or 5 (TIME_STAMP_10)

Widowed? 6 (TIME_STAMP_10)

REFUSED -1 (TIME_STAMP_10)

DON’T KNOW -2 (TIME_STAMP_10)

INTERVIEWER INSTRUCTION: PROBE FOR CURRENT MARITAL STATUS

DE005/(SP_EDUC) . What is the highest degree or level of school that your spouse or partner has completed?

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1

HIGH SCHOOL DIPLOMA OR GED 2

SOME COLLEGE BUT NO DEGREE 3

ASSOCIATE DEGREE 4

BACHELOR’S DEGREE (e.g., BA, BS) 5

POST GRADUATE DEGREE (e.g., Masters or Doctoral) 6

REFUSED -1

DON’T KNOW -2

DE006/(SP_ETHNICITY) . Does your spouse or partner consider himself [OR HERSELF, IF VOLUNTEERED] to be Hispanic, or Latino [LATINA]?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DE007(SP_RACE) . What race does your spouse (or partner) consider himself [OR HERSELF, IF VOLUNTEERED] to be? You may select one or more.

PROBE: Anything else?

SELECT ALL THAT APPLY. ONLY USE “SOME OTHER RACE” IF VOLUNTEERED.

White, 1

Black or African American, 2

American Indian or Alaska Native, 3

Asian, or 4

Native Hawaiian or Other Pacific Islander? 5

SOME OTHER RACE? -5 (SP_RACE_OTH)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO RESPONDENT.

• PROBE FOR ANY OTHER RESPONSES

DE007a/ (SP_RACE_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

FAMILY INCOME

(TIME_STAMP_10) 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?

|___|___|

NUMBER

REFUSED (DE011)/ (INCOME)

DON’T KNOW (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

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• INCLUDE HARD EDIT IF RESPONSE > HH_MEMBERS

• INCLUDE SOFT EDIT IF RESPONSE > 10

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

INTERVIEWER INSTRUCTION: SHOW RESPONDENT CATEGORIES ON SHOW CARD

Less than $4,999 1 (TIME_STAMP_11) $5,000-$9,999 2 (TIME_STAMP_11) $10,000-$19,999 3 (TIME_STAMP_11) $20,000-$29,999 4 (TIME_STAMP_11) $30,000-$39,999 5 (TIME_STAMP_11) $40,000-$49,999 6 (TIME_STAMP_11) $50,000-$74,999 7 (TIME_STAMP_11) $75,000-$99,999 8 (TIME_STAMP_11) $100,000-$199,000 9 (TIME_STAMP_11) $200,000 or more 10 (TIME_STAMP_11) REFUSED -1 (TIME_STAMP_11) DON’T KNOW -2 (TIME_STAMP_11)

TRACING QUESTIONS

(TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TR000. The next set of questions asks about different ways we might be able to keep in touch with you. Please remember that all the information you provide is confidential and will not be provided to anyone outside the National Children’s Study.

TR101/(HAVE_EMAIL). Do you have an email address?

YES 1

NO 2 (TR105) /(CELL_PHONE_1).

REFUSED -1 (TR105) /(CELL_PHONE_1).

DON’T KNOW -2 (TR105) /(CELL_PHONE_1).

TR102/(EMAIL_2). May we use your personal email address to make future study appointments or send appointment reminders?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

TR103/(EMAIL_3). May we use your personal email address for questionnaires (like this one) that you can answer over the Internet?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

TR104/(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

DON’T KNOW -2

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

YES 1

NO 2 (TR001) /(CONTACT_1).

REFUSED -1 (TR001) /(CONTACT_1).

DON’T KNOW -2 (TR001) /(CONTACT_1).

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

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

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

YES 1

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

NO 2

REFUSED -1

DON’T KNOW -2

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

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

PHONE NUMBER

REFUSED -1

DON’T KNOW -2

TR001/(CONTACT_1). sometimes if people move or change their telephone number, we have difficulty reaching them. Could I have the name of a friend or relative not currently living with you who should know where you could be reached in case we have trouble contacting you?

YES 1

NO 2 (TIME_STAMP_12)

REFUSED -1 (TIME_STAMP_12)

DON’T KNOW -2 (TIME_STAMP_12)

TR002/(CONTACT_FNAME_1)/(CONTACT_LNAME_1). What is this person’s name?

______________ __________________

FIRST NAME LAST NAME

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• IF RESPONDENT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TR014/(CONTACT_RELATE_1). What is his/her relationship to you?

MOTHER/FATHER 1

BROTHER/SISTER 2

AUNT/UNCLE 3

GRANDPARENT 4

NEIGHBOR 5

FRIEND 6

OTHER -5 (CONTACT_RELATE1 _OTH)

REFUSED -1

DON’T KNOW -2

Tr014a. (CONTACT_RELATE1_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

TR003/(CONTACT_ADDR_1).What is his/her address?

INTERVIEWER INSTRUCTIONS:

PROMPT AS NECESSARY TO COMPLETE INFORMATION

____________________________________________________

STREET (c_ADDR1_1)/(c_ADDR_2_1)/(c_UNIT_1)

____________________________________________________

CITY (c_CITY_1)

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

STATE ZIP CODE

(c_STATE_1) (c_ZIPCODE_1) (c_ZIP4_1)

REFUSED -1

DON’T KNOW -2

TR004 (CONTACT_PHONE_1). What is his/her telephone number?

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

PHONE NUMBER

CONTACT HAS NO TELEPHONE 1

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

TR005/(CONTACT_2).. Now I’d like to collect information on a second contact who does not currently live with you. What is this person’s name?

INTERVIEWER INSTRUCTION:

CONFIRM SPELLING OF FIRST AND LAST NAMES.

______________ __________________

FIRST NAME LAST NAME

(CONTACT_FNAME_2) (CONTACT_LNAME_2)

NO SECOND CONTACT PROVIDED 1 (TIME_STAMP_12)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• IF RESPONDENT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TR006/(CONTACT_RELATE_2). What is his/her relationship to you?

MOTHER/FATHER 1

BROTHER/SISTER 2

AUNT/UNCLE 3

GRANDPARENT 4

NEIGHBOR 5

FRIEND 6

OTHER -5 (CONTACT_relatE2_oth)

REFUSED -1

DON’T KNOW -2

tr006a. (cONTACT_relatE2_oth)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

TR007/(CONTACT_ADDR_2).. What is his/her address?

INTERVIEWER INSTRUCTIONS:

PROMPT AS NECESSARY TO COMPLETE INFORMATION

____________________________________________________

STREET (C_ADDR1_2)/(C_ADDR_2_2)/(C_UNIT_2)

____________________________________________________

CITY (C_CITY_2)

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

STATE ZIP CODE

(C_STATE_2) (C_ZIPCODE_2) (C_ZIP4_2)

REFUSED -1

DON’T KNOW -2

TR008/(CONTACT_PHONE_2). what is his/her telephone number?

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

PHONE NUMBER

CONTACT HAS NO TELEPHONE 1

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

(TIME_STAMP_12) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

(END). Thank you for participating in the National Children’s Study and for taking the time to complete this survey. This concludes the interview portion of our visit.

INTERVIEWER INSTRUCTION: explain SAQS and RETURN process

INTERVIEW Evaluation

(TIME_STAMP_13) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

ev000. We would now like to take a few minutes to ask some questions about your experience

in the study. There are no right or wrong answers. You can always refuse to answer

any question or group of questions, and your answers will be kept confidential.

EV001. How important was each of the following in your decision to take part in the National Children’s Study?

(LEARN) (How important was…) Learning more about my health or the health of my child?

Not at all important 1

somewhat important 2

Very important 3

(HELP) (How important was…) Feeling as if I can help children now and in the future?

Not at all important 1

somewhat important 2

Very important 3

(INCENT) (How important was…) Receiving money or gifts for taking part in the study?

Not at all important 1

somewhat important 2

Very important 3

(RESEARCH) (How important was…) Helping doctors and researchers learn more about children and their health?

Not at all important 1

somewhat important 2

Very important 3

(ENVIR) (How important was…) Helping researchers learn how the environment may affect children’s health?

Not at all important 1

somewhat important 2

Very important 3

(COMMUNITY) (How important was…) Feeling part of my community?

Not at all important 1

somewhat important 2

Very important 3

(KNOW_OTHERS) (How important was…) Knowing other women in the study?

Not at all important 1

somewhat important 2

Very important 3

(FAMILY) (How important was…) Having family members or friends support my choice to take part in the study?

Not at all important 1

somewhat important 2

Very important 3

(DOCTOR) (How important was…) Having my doctor or health care provider support my choice to take part in the study?

Not at all important 1

somewhat important 2

Very important 3

(STAFF) (How important was…) Feeling comfortable with the study staff who come to my home?

Not at all important 1

somewhat important 2

Very important 3

EV004. How negative or positive do each of the following people feel about you taking part in the National Children’s Study?

(OPIN_SPOUSE) Your spouse or partner

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

programmer instructions: if administered as a casi, skip (opin_spouse) if maristat = 3, 4, 5, 6

(OPIN_FAMILY) Other family members

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

(OPIN_FRIEND) Your friends

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

(OPIN_DR) Your doctor or health care provider

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

EV005/(EXPERIENCE). In general, has your experience with the National Children’s Study been

Mostly negative 1

Somewhat negative 2

Neither negative nor positive 3

Somewhat positive 4

Mostly positive 5

EV007/(IMPROVE). In your opinion, how much do you think the National Children’s Study will help improve the health of children now and in the future?

Not at all 1

A little 2

Some 3

A lot 4

EV008./(INT_LENGTH) Did you think the interview was

Too short 1

Too long, or 2

Just about right? 3

EV009./(INT_STRESS) Do you think the interview was

Not at all stressful 1

A little stressful 2

Somewhat stressful, or 3

Very stressful? 4

EV010./(INT_REPEAT) If you were asked, would you participate in an interview like this again?

Yes 1

No 2

Thank you for participating in the National Children’s Study and for taking the time to complete this survey.

[IF SAQ IS COMPLETED AS A PAPI, SCs MUST PROVIDE INSTRUCTIONS AND A BUSINESS REPLY ENVELOPE FOR RESPONDENT TO RETURN]

(TIME_STAMP_14) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 20 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.