1 Survey
Recruitment Strategy Substudy for the National Children's Study (NICHD)
A.1.3.a T1 Mother Interview_Revised
Pregnancy Activities
OMB: 0925-0593
Appendix
A A.1.1.a–
Visit Type: Enumeration
Target: Adult Household Member
T1 Mother Interview
T1 Mom Visit: Interview Introduction
IN001. Thank you for agreeing to participate in this study. We are about to begin the interview portion of today’s home visit, which will take about an hour to complete. Your answers are important to us. There are no right or wrong answers, just those that help us to understand your situation. There are questions about where you live, your lifestyle routines, and your pregnancy during this interview and you can always refuse to answer any question or group of questions.
(Before we start, can you get the medicines and any pesticide products that you were asked to gather for this appointment?)
IN002. AFTER RESPONDENT GATHERS MATERIALS, OR INDICATES THAT SHE DOESN’T HAVE ANY TO GATHER SAY:
Are you ready to begin?
YES 1
NO 2 (END interview)
T1 Mom Visit: Household Composition and Demographics: Part 1
DE001. First, I’d like to get some information about the people who live here.
DE002. How many people, both children and adults, live in this household? 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 including yourself, what is the total number of people who live here?
|___|___|
NUMBER
REFUSED 9--97
DON’T KNOW 9--98
BOX DE01
CHECK ITEM:
|
DE003. Now I’d like to ask some questions about each person in your household, starting with the oldest. Please list everyone who lives here, except yourself.
DE004. NAME
__________________ UNIQUE FIRST NAME
REFUSED 9--97 DON’T KNOW 9--98
|
DE005. AGE
|___|___|___| AGE
REFUSED 9--97 DON’T KNOW 9--98
|
DE006. GENDER
MALE 1 FEMALE 2 REFUSED 9--97 DON’T KNOW 9--98
|
DE007. RELATIONSHIP
SELF 00 SPOUSE 01 BIOLOGICAL SON/DAUGHTER 02 ADOPTED SON/DAUGHTER 03 STEPSON/STEPDAUGHTER 04 BROTHER/SISTER 05 FATHER/MOTHER 06 GRANDCHILD 07 PARENT-IN-LAW 08 SON-IN-LAW/DAUGHTER-IN-LAW 09 ROOMER, BOARDER 10 HOUSEMATE, ROOMMATE 11 UNMARRIED PARTNER 12 FOSTER CHILD 13 OTHER NONRELATIVE 14 OTHER RELATIVE 15
|
DE008. Now I’d like to ask about your marital status. What is your current marital status? Are you:
INTERVIEWER INSTRUCTION:
CONFIRM IF KNOWN.
Married, 01
Not married but living together with a partner of the opposite sex, 02
Not married but living together with a partner of the same sex, 03
Widowed, 04
Divorced, 05
Separated, or 06
Never been married? 07
REFUSED 9--97
DON’T KNOW 9--98
BEGIN LOOP DE01
|
DE009. {Do you/Does {NAME}} consider {yourself/(himself/herself)} to be Hispanic, or Latino/a?
INTERVIEWER INSTRUCTION:
IF ASKING ABOUT A FEMALE HOUSEHOLD MEMBER READ LATINA.
YES 1
NO 2 (DE011)
REFUSED 9--7 (DE011)
DON’T KNOW 9--8 (DE011)
DE010. Please give me the number of the group that represents {your/NAME’s} Hispanic origin or ancestry.
SHOW CARD DE2.
PUERTO RICAN 01
CUBAN/CUBAN AMERICAN 02
DOMINICAN (REPUBLIC) 03
MEXICAN 04
MEXICAN AMERICAN 05
CENTRAL OR SOUTH AMERICAN 06
OTHER 96
REFUSED 9--97
DON’T KNOW 9--98
DE011. What race {do/does} {you/NAME} consider {yourself/(himself/herself)} to be? You may select one or more.
PROBE: Anything else?
SELECT ALL THAT APPLY.
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? (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
DE012. Please look at the card and tell me what is the highest degree or level of school that {you/NAME} {have/has} completed?
SHOW CARD DE3.
NO SCHOOL 01
ELEMENTARY
NURSERY SCHOOL TO 4TH GRADE 02
5TH-6TH GRADE 03
7TH-8TH GRADE 04
HIGH SCHOOL
9TH GRADE 05
10TH GRADE 06
11TH GRADE 07
12TH GRADE (NO DIPLOMA) 08
HIGH SCHOOL DIPLOMA 09
GED OR EQUIVALENT 10
COLLEGE
SOME COLLEGE CREDITS, BUT LESS THAN 1 YEAR 11
1 OR MORE YEARS OF COLLEGE, BUT NO DEGREE 12
ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR
VOCATIONAL PROGRAM 13
ASSOCIATE DEGREE: ACADEMIC PROGRAM 14
BACHELOR’S DEGREE (e.g., BA, BS) 15
GRADUATE
MASTER’S DEGREE (e.g., MA, MS, MSW, MEng, MBA) 16
PROFESSIONAL SCHOOL DEGREE (e.g., MD, DDS, DVM, JD) 17
DOCTORAL DEGREE (e.g., Ph.D., Ed.D.) 18
REFUSED 9--97
DON’T KNOW 9--98
END LOOP DE01
|
T1 Mom Visit: Current Pregnancy Information
CP001. Now I’d like to change the subject and ask some questions about you, your health, and your health history. I’ll begin by asking about your current pregnancy.
CP002. What was the first day of your last menstrual period?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97 (CP004)
DON’T KNOW 9--98 (CP004)
CP003. DID RESPONDENT GIVE DATE?
RESPONDENT GAVE COMPLETE DATE 1
INTERVIEWER ENTERED 15 FOR DAY 2
CP004. About how many weeks pregnant were you when you first learned that you were pregnant?
|___|___|
WEEKS
REFUSED 9--97
DON’T KNOW 9--98
CP005. Since you became pregnant, have you seen a doctor or other health care provider about this pregnancy?
YES 1
NO 2 (CP011)
REFUSED 9--97 (CP011)
DON’T KNOW 9--98 (CP011)
CP006. Is your prenatal provider a family practitioner or internist, an obstetrician/gynecologist, a nurse midwife, or some other type of provider?
FAMILY PRACTITIONER/INTERNIST 1
OB/GYN 2
NURSE MIDWIFE 3
OTHER PROVIDER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
CP007. Has a doctor or other health care provider given you a due date?
YES 1
NO 2 (CP010)
REFUSED 9--97 (CP010)
DON’T KNOW 9--98 (CP010)
CP008. What is that due date?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97 (CP010)
DON’T KNOW 9--98 (CP010)
CP009. DID RESPONDENT GIVE DATE?
RESPONDENT GAVE COMPLETE DATE 1
INTERVIEWER ENTERED 15 FOR DAY 2
CP010. QUESTION DELETED
CP011. Where do you plan to deliver your baby:
In a hospital, 1
A birthing center, 2
At home, or 3 (CP013)
Some other place? 4
REFUSED 9--97 (CP013)
DON’T KNOW 9--98 (CP013)
CP012. What is the name and address of this place?
_____________________________________________________
NAME OF BIRTH HOSPITAL/BIRTHING CENTER
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___| |___|___|___|___|___|
STATE ZIP CODE
REFUSED 9--97
DON’T KNOW 9--98
CP013. QUESTION DELETED
CP014. QUESTION DELETED
CP014A. QUESTION DELETED
CP015. QUESTION DELETED
CP016. QUESTION DELETED
CP016A. QUESTION DELETED
CP016B. QUESTION DELETED
CP016C. QUESTION DELETED
CP016D. QUESTION DELETED
CP017. Since you became pregnant on how many days have you had a fever over 101 degrees? (IF NEEDED: or 38.3 degrees Celsius?)
|___|___|___|
NUMBER OF DAYS
REFUSED 9--97
DON’T KNOW 9--98
CP018. QUESTION DELETED
CP019. QUESTION DELETED
CP020. QUESTION DELETED
CP021. QUESTION DELETED
CP022. QUESTION DELETED
CP023. QUESTION DELETED
CP024. QUESTION DELETED
CP025. QUESTION DELETED
CP026. Did you or your partner go to a doctor or other health care provider to talk about ways to help you become pregnant this time?
YES 1
NO 2 (CP034)
REFUSED 9--97 (CP034)
DON’T KNOW 9--98 (CP034)
CP027. What types of services or treatments shown on this card did you receive to help you become pregnant with this pregnancy?
SHOW CARD CP1.
SELECT ALL THAT APPLY.
ADVICE ONLY 01
MEDICINES OR SHOTS to improve your ovulation 02
surgery to cORRECT BLOCKED TUBES 03
OTHER TYPE OF SURGERY (SPECIFY): 04
ARTIFICIAL INSEMINATION 05
in vitro fertilization 06
OTHER TYPES OF MEDICAL HELP (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
BOX CP03
CHECK ITEM:
|
CP028. Please tell me who donated the sperm. Was it:
HUSBAND OR PARTNER, 1
A DONOR, OR 2
BOTH YOUR HUSBAND OR PARTNER AND A DONOR? 3
REFUSED 9--97
DON’T KNOW 9--98
BOX CP04
CHECK ITEM:
|
CP029. As part of in vitro fertilization, sometimes a donor egg is used. Was a donor egg used for your in vitro fertilization?
YES 1
NO 2 (BOX CP05)
REFUSED 9--97 (BOX CP05)
DON’T KNOW 9--98 (BOX CP05)
CP030. Please tell me who donated the egg. Was it:
A relative that you are biologically related to, 1
A relative that you are not biologically related to, 2
A friend, 3
An anonymous donor, or 4
Some other person? (SPECIFY): 5
REFUSED 9--97
DON’T KNOW 9--98
CP032. QUESTION DELETED
BOX CP05
CHECK ITEM:
|
CP033. Which of the drugs shown on this card did you use to improve your ovulation for this pregnancy?
SHOW CARD CP3.
SELECT ALL that apply.
CLOMID 01
GONAL F 02
BRAVELLE 03
FOLLISTIM 04
REPRONEX 05
PERGONAL 06
PREGNYL 07
PROFASI 08
NOVAREL 09
OTHER DRUG (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
BOX CP06
CHECK ITEM:
|
CP034. Part of the National Children’s Study may include a study visit with the baby’s biological father. What is the first and last name of your baby’s biological father?
____________________ ________________________
FIRST NAME LAST NAME
REFUSED 9--97 (CP038)
DON’T KNOW 9--98 (EOS)
CP035. Is the biological father of your baby living in this household?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
CP036. May the study contact him?
YES 1
NO 2 (CP038)
REFUSED 9--97 (CP038)
DON’T KNOW 9--98 (CP038)
BOX CP07
CHECK ITEM:
|
CP037. What is his home address and phone number?
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___| |___|___|___|___|___|
STATE ZIP CODE
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
REFUSED 9--97
DON’T KNOW 9--98
CP038. Is this the first pregnancy with this partner?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
T1 Mom Visit: Maternal Birth History
MB001. Next, I’d like to ask you about your birth.
MB002. W
ere
you born prematurely, that is more than 3 weeks early?
YES 1
NO 2 (MB004)
REFUSED 9--97 (MB004)
DON’T KNOW 9--98 (MB004)
MB003. How many weeks early were you born?
|___|___|
WEEKS
REFUSED 9--97
DON’T KNOW 9--98
MB004. How much did you weigh when you were born?
|___|___| AND |___|___| (MB006)
POUNDS OUNCES
OR
|___|___|___|___| (MB006)
GRAMS
REFUSED 9--97 (MB006)
DON’T KNOW 9--98 (MB005)
MB005. Were you a low birth weight baby, that is, did you weigh less than 5 pounds 8 ounces (2500 grams) or 5 pounds 8 ounces (2500 grams) at birth?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MB006. When you were born, were you born as a singleton, twin, triplet, or some other multiple birth?
SINGLETON 1
TWIN 2
TRIPLET 3
OTHER (SPECIFY): 4
REFUSED 9--97
DON’T KNOW 9--98
T1 Mom Visit: Maternal Medical History
MC001. Next, I have some general questions about your health.
MC002. Would you say your health in general is . . .
Excellent, 1
Very good, 2
Good, 3
Fair, or 4
Poor? 5
REFUSED 9--97
DON’T KNOW 9--98
MC003. QUESTION DELETED
MC004. QUESTION DELETED
MC005. QUESTION DELETED
MC006. Next are some questions about dental health and gum disease. Gum disease is a common problem. People with gum disease might have swollen gums, receding gums, sore or infected gums, or loose teeth.
MC007. Do you think you might have gum disease?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC008. Overall, how would you rate the health of your teeth and gums?
Excellent, 1
Very good, 2
Good, 3
Fair, or 4
Poor? 5
REFUSED 9--97
DON’T KNOW 9--98
MC009. In the past 12 months, have you had treatment for gum disease such as scaling and root planing, sometimes called “deep cleaning”? This does not include visits to the dentist just for routine cleanings.
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC010. Have you ever been told by a dental professional that you have lost bone around your teeth?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC011. The next questions are about medical conditions or health problems you might have or may have had.
MC012. Have you ever been told by a doctor or other health care provider that you had asthma?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC013. (Have you ever been told by a doctor or other health care provider that you had:) Eczema or atopic dermatitis?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC014. (Have you ever been told by a doctor or other health care provider that you had:) Seasonal allergies?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC015. (Have you ever been told by a doctor or other health care provider that you had:) Any other allergies?
YES 1
NO 2 (MC017)
REFUSED 9--97 (MC017)
DON’T KNOW 9--98 (MC017)
MC016. What type of allergy do you have?
SELECT ALL THAT APPLY.
PEANUTS 1
BEE STINGS 2
SHELLFISH 3
CATS 4
DOGS 5
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
MC017. (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?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC018. (Have you ever been told by a doctor or other health care provider that you had:) Diabetes when you’re not pregnant?
YES 1
NO 2 (MC023)
REFUSED 9--97 (MC023)
DON’T KNOW 9--98 (MC023)
MC019. Have you taken any medicine or received other medical treatment for this in the past 12 months?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC020. Have you ever taken insulin?
YES 1
NO 2 (MC023)
REFUSED 9--97 (MC023)
DON’T KNOW 9--98 (MC023)
MC021. Right before you became pregnant this time, were you taking medication by mouth for diabetes?
IF NEEDED: For example, pills
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC022. Right before you became pregnant this time, were you taking Insulin, either by injection or by pump?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC023. (Have you ever been told by a doctor or other health care provider that you had:) High cholesterol?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC024. (Have you ever been told by a doctor or other health care provider that you had:) Ovarian cysts or polycystic ovarian syndrome (PCOS)?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC025. (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 (MC027)
REFUSED 9--97 (MC027)
DON’T KNOW 9--98 (MC027)
MC026. Have you taken any medicine or received other medical treatment for this in the past 12 months?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC027. (Have you ever been told by a doctor or other health care provider that you had:) Hyperthyroidism, that is, an overactive thyroid?
YES 1
NO 2 (MC029)
REFUSED 9--97 (MC029)
DON’T KNOW 9--98 (MC029)
MC028. Have you taken any medicine or received other medical treatment for this in the past 12 months?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC029. (Have you ever been told by a doctor or other health care provider that you had:) Anorexia nervosa?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC030. (Have you ever been told by a doctor or other health care provider that you had:) Bulimia?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC031. (Have you ever been told by a doctor or other health care provider that you had:) Any type of cancer?
YES 1
NO 2 (MC033)
REFUSED 9--97 (MC033)
DON’T KNOW 9--98 (MC033)
MC032. What type or types of cancer were you diagnosed with?
SELECT ALL THAT APPLY.
BRAIN 1
BREAST 2
CERVICAL 3
COLON 4
HODGKIN’S LYMPHOMA 5
LEUKEMIA 6
LIVER 7
LUNG 8
NON-HODGKIN’S LYMPHOMA 9
OVARIAN 10
SKIN 11
THYROID 12
UTERINE 13
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
MC033. (Have you ever been told by a doctor or other health care provider that you had:) Sickle cell anemia or sickle cell trait?
YES 1
NO 2 (MC035)
REFUSED 9--97 (MC035)
DON’T KNOW 9--98 (MC035)
MC034. Which do you have?
SICKLE CELL ANEMIA 1
SICKLE CELL TRAIT 2
REFUSED 9--97
DON’T KNOW 9--98
MC035. (Have you ever been told by a doctor or other health care provider that you had:) An autoimmune disorder such as rheumatoid arthritis, lupus, or scleroderma?
YES 1
NO 2 (MC037)
REFUSED 9--97 (MC037)
DON’T KNOW 9--98 (MC037)
MC036. What type of autoimmune disorder were you diagnosed with?
RHEUMATOID ARTHRITIS 01
LUPUS 02
SCLERODERMA 03
MULTIPLE SCLEROSIS 04
GRAVES’ DISEASE 05
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
MC037. (Have you ever been told by a doctor or other health care provider that you had:) Migraines?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC038. (Have you ever been told by a doctor or other health care provider that you had:) Epilepsy or seizures?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC039. (Have you ever been told by a doctor or other health care provider that you had:) Sleep apnea?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC040. (Have you ever been told by a doctor or other health care provider that you had:) Blindness or any severe vision impairment?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC041. (Have you ever been told by a doctor or other health care provider that you had:) Deafness or any severe hearing impairment?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC042. (Have you ever been told by a doctor or other health care provider that you had:) Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC043. (Have you ever been told by a doctor or other health care provider that you had:) Autism, Asperger syndrome, or any other autism spectrum disorder?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC044. (Have you ever been told by a doctor or other health care provider that you had:) Bipolar disorder?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC045. (Have you ever been told by a doctor or other health care provider that you had:) Depression, other than bipolar disorder?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC046. (Have you ever been told by a doctor or other health care provider that you had:) An anxiety disorder, such as generalized anxiety disorder or obsessive compulsive disorder (OCD)?
YES 1
NO 2 (MC047)
REFUSED 9--97 (MC047)
DON’T KNOW 9--98 (MC047)
MC047. What type of anxiety disorder were you diagnosed with?
SELECT ALL THAT APPLY.
GENERALIZED ANXIETY DISORDER 01
OBSESSIVE COMPULSIVE DISORDER 02
SOCIAL PHOBIA 03
SPECIFIC PHOBIA 04
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
MC048. (Have you ever been told by a doctor or other health care provider that you had:) HIV or AIDS?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC049. (Have you ever been told by a doctor or other health care provider that you had:) Hepatitis B?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
MC050. (Have you ever been told by a doctor or other health care provider that you had:) Any other chronic or long lasting conditions?
YES 1
NO 2 (EOS)
REFUSED 9--97 (EOS)
DON’T KNOW 9--98 (EOS)
MC051. What other chronic condition or conditions were you diagnosed with?
___________________________
OTHER CONDITION
REFUSED 9--97
DON’T KNOW 9--98
MC052. In general, do you consider yourself to be right-handed, left-handed, or both (ambidextrous)?
RIGHT-HANDED 1
LEFT-HANDED 2
BOTH/AMBIDEXTROUS 3
REFUSED 9--97
DON’T KNOW 9--98
T1 Mom Visit: Health Behaviors Part 1
HB001. QUESTION DELETED
HB002. QUESTION DELETED
HB003. QUESTION DELETED
HB004. QUESTION DELETED
HB005. QUESTION DELETED
HB006. QUESTION DELETED
HB007. QUESTION DELETED
HB008. QUESTION DELETED
HB009. QUESTION DELETED
HB010. QUESTION DELETED
HB011. QUESTION DELETED
HB012. QUESTION DELETED
HB013. QUESTION DELETED
HB014. QUESTION DELETED
HB015. QUESTION DELETED
HB016. QUESTION DELETED
HB017. Now I’d like to change topics and ask you some questions about drinking beverages with caffeine.
HB018. In the 3 months before you knew you were pregnant, did you drink:
IF YES: How many of these drinks did you have per day?
INTERVIEWER INSTRUCTION:
IF ANSWER IS “NO” WRITE IN “0” FOR HOW MANY PER DAY.
IF RESPONDENT DRINKS LESS THAN 1 DRINK PER DAY, WRITE IN “0” FOR HOW MANY PER DAY.
HOW
MANY
YES NO PER DAY RF DK
a. Caffeinated coffee? 1 2 |___|___| 9--97 9--98
b. Caffeinated tea? 1 2 |___|___| 9--97 9--98
c. Soda with caffeine (Coke, Pepsi, Dr. Pepper, Mountain Dew)? 1 2 |___|___| 9--97 9--98
d. Energy drinks with caffeine (Red Bull, Amp)? 1 2 |___|___| 9--97 9--98
HB019. Currently, do you drink:
IF YES: How many of these drinks do you have per day?
INTERVIEWER INSTRUCTION:
IF ANSWER IS “NO” WRITE IN “0” FOR HOW MANY PER DAY.
IF RESPONDENT DRINKS LESS THAN 1 DRINK PER DAY, WRITE IN “0” FOR HOW MANY PER DAY.
HOW
MANY
YES NO PER DAY RF DK
a. Caffeinated coffee? 1 2 |___|___| 9--97 9--98
b. Caffeinated tea? 1 2 |___|___| 9--97 9--98
c. Soda with caffeine (Coke, Pepsi, Dr. Pepper, Mountain Dew)? 1 2 |___|___| 9--97 9--98
d. Energy drinks with caffeine (Red Bull, Amp)? 1 2 |___|___| 9--97 9--98
T1 Mom Visit: Use of Medicines, Supplements and Alternative Medicines
UM001. The next questions are about your use of prescription medications, over the counter medications, and dietary supplements.
UM002. Since you became pregnant, have you used or taken medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. Please include prescription vitamins or minerals.
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
UM003. Since you became pregnant, have you used or taken any over-the-counter or nonprescription medications, or any nonprescription vitamins, minerals, herbals, or other dietary supplements? This card lists some examples of different types of over the counter medications, vitamins, minerals, and dietary supplements.
SHOW CARD UM1.
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
BOX UM01
CHECK ITEM:
|
UM004. May I please see the containers for all the {prescriptions,} {and} {non-prescription medicines and supplements}, that you used or took since you became pregnant?
RESPONDENT HAS CONTAINERS 1
RESPONDENT DOES NOT HAVE CONTAINERS 2
DISPLAY INSTRUCTIONS:
IF UM002 AND UM003 = 1, DISPLAY “{and}”.
IF UM002 = “1” DISPLAY “{prescription medicines,}”.
IF UM003 = “1” DISPLAY “{and non-prescription medicines and supplements}”.
BOX UM02
CHECK ITEM:
|
UM005. I will start with the prescription medications. {Please show me any you have taken since you became pregnant/ Please tell me the names of the prescription medications and supplements that you have taken since you became pregnant}.
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER. ACTIVATE LOOKUP AND SELECT MEDICATIONS FROM LIST. IF A MEDICATION IS NOT ON LIST, ENTER THE FULL NAME (INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
PRODUCT ON PRESCRIPTION MEDICINE LIST 1
PRODUCT NOT ON LIST (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
DISPLAY INSTRUCTION:
IF UM004 = “1”, DISPLAY “{Please show me any you have taken since you became pregnant}”.
IF UM004 = “2”, DISPLAY “{Please tell me the names of the prescription medications and supplements that you have taken since you became pregnant}”.
BEGIN LOOP UM01
LOOP:
|
UM006. Let’s talk about {MEDICATION}.
UM007. PRODUCT LABEL SEEN?
YES 1
NO 2
UM008. RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK: How is the {MEDICATION} taken?
By mouth, 01
Inhaled either by mouth or nose, 02
Injected, 03
Applied to the skin, such as a patch or creams, or 04
Some other way? (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
UM009. When did you start taking {MEDICATION}?
Before you became pregnant, 1
In your first month of pregnancy, or 2
After your first month of pregnancy? 3
REFUSED 9--97
DON’T KNOW 9--98
UM010. Are you still taking {MEDICATION}?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
UM011. How often {do/did} you use or take {MEDICATION}?
|___|___|
ENTER NUMBER
ENTER UNIT
PER DAY 1
PER WEEK 2
PER MONTH 3
PER YEAR 4
AS NEEDED 9--95
REFUSED 9--97
DON’T KNOW 9--98
END LOOP UM01
LOOP:
|
BOX UM03
CHECK ITEM:
|
UM012. Now let’s talk about your use of over-the-counter medications, and nonprescription vitamins, minerals, herbals, and other dietary supplements. {Please show me any you have taken since you became pregnant/Please tell me the names of the nonprescription medications and nonprescription vitamins, minerals, herbals, and supplements that you have taken since you became pregnant}
INTERVIEWER INSTRUCTION:
CHECK PRODUCT LABEL OR ASK PRODUCT NAME IF RESPONDENT DOESN’T PROVIDE CONTAINER. ACTIVATE LOOKUP AND SELECT PRODUCT FROM LIST. IF PRODUCT NOT ON LIST, ENTER THE FULL NAME (INCLUDING BRAND NAME) IN THE SPECIFY FIELD.
SHOW CARD UM1.
PRODUCT ON MEDICINE LIST 1
PRODUCT NOT ON LIST (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
DISPLAY INSTRUCTION:
IF UM004 = “1”, DISPLAY “{Please show me any you have taken since you became pregnant}”.
IF UM004 = “2”, DISPLAY “{Please tell me the names of the nonprescription medications and nonprescription vitamins, minerals, herbals, and supplements that you have taken since you became pregnant}”.
BEGIN LOOP UM02
LOOP:
|
UM013. Let’s talk about {PRODUCT}.
UM014. WAS PRODUCT LABEL SEEN?
YES 1
NO 2
UM015. RECORD FORM FROM PRODUCT CONTAINER. IF RESPONDENT DOESN’T PROVIDE CONTAINER, ASK: How is this {PRODUCT} taken?
By mouth, 01
Inhaled either by mouth or nose, 02
Injected, 03
Applied to the skin, such as a patch or creams, or 04
Some other way? (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
UM016. When did you start taking {PRODUCT}?
Before you became pregnant, 1
In your first month of pregnancy, or 2
After your first month of pregnancy? 3
REFUSED 9--97
DON’T KNOW 9--98
UM017. Since you became pregnant, how often have you taken {PRODUCT}?
Less than once a month, 01
Once a month, 02
2-3 times a month (but less than once a week), 03
1-2 times a week, 04
3-4 times a week, 05
5-6 times a week, or 06
Every day? 07
REFUSED 9--97
DON’T KNOW 9--98
UM018. Are you still taking {PRODUCT}?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
END LOOP UM02
LOOP:
|
T1 Mom Visit: Doctor Visits and Hospitalizations
DV001. I am now going to ask some questions about visits to a doctor or other health care provider. It would be helpful if you referred to the Medical Care Log that you received as part of this study or to any other personal record or calendar that you keep that would help you to remember the dates of these visits. If you have this information available, please go and get it now.
BOX DV00
CHECK ITEM:
|
DV002. Not including any overnight hospital stays, have you seen a doctor or other heath care provider since you became pregnant? Please include routine pregnancy checkups, sonograms or ultrasounds and other tests, as well as any other visits to a doctor or other health care provider because you were sick or injured, or for any other reason. (These would be the visits you noted in the yellow part of your Medical Care Log.)
YES 1
NO 2 (DV017)
REFUSED 9--97 (DV017)
DON’T KNOW 9--98 (DV017)
BEGIN LOOP DV01
LOOP:
|
DV003. What was the date of {your/the next} most recent visit or checkup?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97
DON’T KNOW 9--98
DV004. What kind of place did you go to? Was it a:
Doctor’s office, clinic, or health center 1
Hospital emergency room 2
Urgent care center, or 3
Some other place (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
DV005. What was the main reason for the visit? Was it for:
Routine pregnancy care, 1
Illness or injury, or 2 (DV012)
Some other reason? (SPECIFY): 6 (DV012)
REFUSED 9--97 (DV012)
DON’T KNOW 9--98 (DV012)
DV005a. What type of provider did you see? Was it an:
Obstetrician/Gynecologist, 1
Family physician, 2
Nurse/Midwife, or 3
Another type of provider (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
DV006. At this visit, was your weight measured?
YES 1
NO 2 (DV008)
REFUSED 9--97 (DV008)
DON’T KNOW 9--98 (DV008)
DV007. At this visit, what was your weight?
|___|___|___|.|___|
WEIGHT
POUNDS 1
KILOGRAMS 2
REFUSED 9--97
DON’T KNOW 9--98
DV008. At this visit, was your blood pressure measured?
YES 1
NO 2 (DV011)
REFUSED 9--97 (DV011)
DON’T KNOW 9--98 (DV011)
DV009. At this visit, what was your blood pressure?
|___|___|___|
SYSTOLIC BLOOD PRESSURE
|___|___|___|
DIASTOLIC BLOOD PRESSURE
REFUSED 9--97
DON’T KNOW 9--98
DV010. QUESTION DELETED
DV011. At this visit, were any of the following procedures performed?
YES NO RF DK
a. Ultrasound or sonogram? 1 2 9--97 9--98
b. Amniocentesis? 1 2 9--97 9--98
c. Chorionic Villus Sampling or CVS? 1 2 9--97 9--98
d. Any other test or procedure? (SPECIFY): 1 2 9--97 9--98
BOX DV03
CHECK ITEM:
|
DV012. Did the doctor or other health care provider give you any diagnosis at this visit?
YES 1 (DV013a)
NO 2 (DV014)
REFUSED 9--97 (DV014)
DON’T KNOW 9--98 (DV014)
DV013. At this visit, did the doctor or other health care provider tell you that you have any of the following conditions?
YES NO RF DK
a. Diabetes? 1 2 9--97 9--98
b. High blood pressure? 1 2 9--97 9--98
c. Protein in your urine? 1 2 9--97 9--98
d. Preeclampsia or toxemia? 1 2 9--97 9--98
e. Early or premature labor? 1 2 9--97 9--98
f. Anemia? 1 2 9--97 9--98
g. Severe nausea or hyperemisis? 1 2 9--97 9--98
h. Bladder or kidney Infection 1 2 9--97 9--98
i. Rh disease or isoimmunization? 1 2 9--97 9--98
j. Group B strep? 1 2 9--97 9--98
k. Herpes? 1 2 9--97 9--98
l. Bacterial vaginosis? 1 2 9--97 9--98
m. Pelvic inflammatory disease (PID), or infection in your tubes? 1 2 9--97 9--98
n. Other sexually transmitted disease or infection, such as chlamydia,
syphilis, or gonorrhea? 1 2 9--97 9--98
o. Any other serious condition? (SPECIFY): 1 2 9--97 9--98
DV013a. What was the diagnosis?
SELECT ALL THAT APPLY.
COLD OR UPPER RESPIRATORY INFECTION 1
BLADDER OR KIDNEY INFECTION 2
FEVER 3
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
DV014. Were you given any vaccinations at this visit? Vaccinations are usually injections or shots that strengthen people’s immune systems so that their bodies can fight off serious infectious diseases. Do not include allergy shots or Rhogam injections.
YES 1
NO 2 (DV016)
REFUSED 9--97 (DV016)
DON’T KNOW 9--98 (DV016)
DV015. What type of vaccination did you receive?
SELECT ALL THAT APPLY.
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT ANSWERS “TETANUS”, PROBE WHETHER SHE RECEIVED TETANUS/DIPHTHERIA (Td), or TETANUS, DIPHTHERIA AND PERTUSSIS (Tdap). IF SHE IS NOT SURE, SELECT “TETANUS/DIPHTHERIA (Td)”.
IF THE RESPONDENT ANSWERS “HEPATITIS”, PROBE TO FIND OUT WHETHER IT WAS FOR HEPATITIS A OR HEPATITIS B.
FLU/INFLUENZA 01
HEPATITIS B 02
HEPATITIS A 03
TETANUS/DIPHTHERIA (Td) 04
TETANUS, DIPHTHERIA AND PERTUSSIS (Tdap) 05
MENINGOCOCCAL 06
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9—98
DV016. Have you had any other visits to a doctor or other health care provider since you became pregnant?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
END LOOP DV01
LOOP:
|
DV017. Since you became pregnant, have you spent at least one night in the hospital?
YES 1
NO 2 (BOX DV04)
REFUSED 9--97 (BOX DV04)
DON’T KNOW 9--98 (BOX DV04)
BEGIN LOOP DV02
LOOP:
|
DV018. What was the admission date of your {next} most recent hospital stay?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97
DON’T KNOW 9--98
DV019. How many nights did you stay in the hospital during this hospital stay?
|___|___|___|
NUMBER OF NIGHTS
REFUSED 9--97
DON’T KNOW 9--98
DV020. Did a doctor or other health care provider give you a diagnosis during this hospital stay?
YES 1
NO 2 (DV022)
REFUSED 9--97 (DV022)
DON’T KNOW 9--98 (DV022)
DV021. What was the diagnosis?
SELECT ALL THAT APPLY.
DEHYDRATION 01
PRETERM LABOR 02
HYPEREMISIS 03
PREECLAMPSIA 04
RUPTURE OF MEMBRANES 05
KIDNEY DISORDER 06
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
DV022. Did you receive any treatments during this hospital stay? Please include any vaccinations you may have received.
YES 1
NO 2 (DV024)
REFUSED 9--97 (DV024)
DON’T KNOW 9--98 (DV022)
DV023. What treatments did you receive?
_____________________________________________________
TREATMENTS
REFUSED 9--97
DON’T KNOW 9--98
DV024. Have you had any other hospital stays since you became pregnant?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
END LOOP DV02
LOOP:
|
BOX DV04
CHECK ITEM:
|
DV025. Part of the National Children’s Study includes an early sonogram or ultrasound to help determine the exact age of your baby.
DV026. Do you have a sonogram or ultrasound scheduled?
YES 1
NO 2 (EOS)
REFUSED 9--97 (EOS)
DON’T KNOW 9--98 (EOS)
DV027. What is the date of your sonogram or ultrasound appointment?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97
DON’T KNOW 9--98
T1 Mom Visit: Housing Characteristics
HC001. Now I’d like to change the subject and find out more about your home and the area in which you live.
HC002. 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 (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
HC003. QUESTION DELETED
HC004. Can you tell us, which of these categories do you think best describes when your home or building was built?
SHOW CARD HC1.
2001 TO PRESENT 01
1981 TO 2000 02
1961 TO 1980 03
1941 TO 1960 04
1940 OR BEFORE 05
REFUSED 9--97
DON’T KNOW 9--98
HC005. How long have you lived in this home?
|___|___|
NUMBER
WEEKS 1
MONTHS 2
YEARS 3
REFUSED 9--97
DON’T KNOW 9--98
HC006. Now I’m going to ask about how your home is heated and cooled.
HC007. Which of these types of heat sources best describes the main heating fuel source for your home?
SHOW CARD HC2.
ELECTRIC 01
GAS – PROPANE OR LP 02
OIL 03
WOOD 04
KEROSENE OR DIESEL 05
COAL OR COKE 06
SOLAR ENERGY 07
HEAT PUMP 08
NO HEATING SOURCE 09 (HC011)
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
HC008. 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?
SHOW CARD HC2.
SELECT ALL THAT APPLY.
ELECTRIC 01
GAS – PROPANE OR LP 02
OIL 03
WOOD 04
KEROSENE OR DIESEL 05
COAL OR COKE 06
SOLAR ENERGY 07
HEAT PUMP 08
NO OTHER HEATING SOURCE 09
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
HC009. QUESTION DELETED
HC010. QUESTION DELETED
HC011. Does your home have any type of cooling or air conditioning?
YES 1
NO 2 (BOX HC01)
REFUSED 9--97 (BOX HC01)
DON’T KNOW 9--98 (BOX HC01)
HC012. Which of the following kinds of cooling systems do you regularly use? Do not include fans.
SELECT ALL THAT APPLY.
Window or wall air conditioners, 01
Central air conditioning, 02
Evaporative cooler (swamp cooler), or 03
NO COOLING OR AIR CONDITIONING REGULARLY USED 04
Some other cooling system (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
HC013. QUESTION DELETED
HC014. QUESTION DELETED
BOX HC01
|
HC015. Does your furnace or air conditioning system use a special HEPA (High Efficiency Particulate Air) or other special allergy filter to filter the air?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
HC016. QUESTION DELETED
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. In the past 12 months, have you seen any water damage inside your home?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
HC019. 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 (HC021)
REFUSED 9--97 (HC021)
DON’T KNOW 9--98 (HC021)
HC020. In which rooms have you seen the mold or mildew?
PROBE: Any other rooms?
SELECT ALL THAT APPLY.
KITCHEN 01
LIVING ROOM 02
HALL/LANDING 03
RESPONDENT’S BEDROOM 04
OTHER BEDROOM 05
BATHROOM/TOILET 06
BASEMENT 07
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
HC021. The next few questions ask about any recent additions or renovations to your home.
HC022. Since you became pregnant, 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 that were just painting or wallpapering.
YES 1
NO 2 (HC024a)
REFUSED 9--97 (HC024a)
DON’T KNOW 9--98 (HC024a)
HC023. QUESTION DELETED
HC024. Which rooms were renovated?
PROBE: Any others?
SELECT ALL THAT APPLY.
KITCHEN 01
LIVING ROOM 02
HALL/LANDING 03
RESPONDENT’S BEDROOM 04
OTHER BEDROOM 05
BATHROOM/TOILET 06
BASEMENT 07
OTHER (SPECIFY): 08
REFUSED 9--97
DON’T KNOW 9--98
HC024a. Since you became pregnant, were any smaller projects done in your home, such as painting, wallpapering, refinishing floors, or installing new carpet?
YES 1
NO 2 (HC033)
REFUSED 9--97 (HC033)
DON’T KNOW 9--98 (HC033)
HC024b. In which rooms were these smaller projects done?
PROBE: Any others?
SELECT ALL THAT APPLY.
KITCHEN 01
LIVING ROOM 02
HALL/LANDING 03
RESPONDENT’S BEDROOM 04
OTHER BEDROOM 05
BATHROOM/TOILET 06
BASEMENT 07
OTHER (SPECIFY): 08
REFUSED 9--97
DON’T KNOW 9--98
HC025. QUESTION DELETED
HC026. QUESTION DELETED
HC027. QUESTION DELETED
HC028. QUESTION DELETED
HC029. QUESTION DELETED
HC030. QUESTION DELETED
HC031. QUESTION DELETED
HC032. QUESTION DELETED
HC033. Now I’d like to ask about the water in your home.
HC034. 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? (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
HC035. 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? (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
HC036. Now, a couple of questions about your neighborhood.
HC037. In your opinion, is your neighborhood…
A very good place to live, 1
A fairly good place to live, 2
Not a very good place to live, or 3
Not at all a good place to live? 4
REFUSED 9--97
DON’T KNOW 9--98
HC038. Do you feel that your neighborhood is…
Very safe, 1
Somewhat safe, 2
Somewhat unsafe, or 3
Very unsafe? 4
REFUSED 9--97
DON’T KNOW 9--98
T1 Mom Visit: Product Use
PR001. These questions ask about some different types of products you may have used to take care of yourself, your family, or your home. Please choose your answer from one of these categories.
SHOW CARD PR1.
PR002. Since you became pregnant, how often have you used the following types of products:
SHOW CARD PR1.
A LESS
FEW ABOUT 1-3 THAN
TIMES ONCE TIMES ONCE NOT
EVERY A A A A AT
DAY WEEK WEEK MONTH MONTH ALL RF DK
a. Bleach? 01 02 03 04 05 06 9--97 9--98
b. Disinfectants
other than bleach, such
as
Lysol? 01 02 03 04 05 06 9--97 9--98
c. Window or glass cleaner? 01 02 03 04 05 06 9--97 9--98
d. Carpet cleaner? 01 02 03 04 05 06 9--97 9--98
e. Any
type of air fresheners including
spray, stick, aerosol, or
plug-in? 01 02 03 04 05 06 9--97 9--98
f. Other
aerosols or sprays of any kind,
including hair
spray? 01 02 03 04 05 06 9--97 9--98
g. Paint or varnish? 01 02 03 04 05 06 9--97 9--98
h. Turpentine,
mineral spirits, or paint
thinner? 01 02 03 04 05 06 9--97 9--98
i. Other types of paint stripper? 01 02 03 04 05 06 9--97 9--98
PR003. QUESTION DELETED
PR004. QUESTION DELETED
PR005. QUESTION DELETED
PR006. QUESTION DELETED
PR007. Since you became pregnant, about how often have you used any insect repellent spray, lotion, or towelettes on yourself or someone else?
Every day, 01
A few times a week, 02
About once a week, 03
1-3 times a month, 04
Less than once a month, or 05
Not at all? 06 (PR009)
REFUSED 9--97 (PR009)
DON’T KNOW 9--98 (PR009)
PR008. Did the insect repellent contain DEET? (DEET is usually listed next to the name of the product or in the ingredient list on the label.)
YES 1
NO 2
USED BOTH REPELLENT WITH DEET AND WITHOUT DEET 3
REFUSED 9--97
DON’T KNOW 9--98
PR009. Since you became pregnant, have you been treated or did you treat other people in your home for lice or scabies?
YES 1
NO 2 (PR011)
REFUSED 9--97 (PR011)
DON’T KNOW 9--98 (PR011)
PR010. What product did you use to treat lice or scabies?
PROBE: Anything else?
SELECT ALL THAT APPLY.
ACTICIN 01
ELIMITE 02
EURAX 03
GENERIC/DRUGSTORE BRAND LICE/SCABIES PRODUCT 04
KWELL/KWELLEDA 05
NIX 06
OVIDE 07
RID 08
stromectol 09
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
PR011. QUESTION DELETED
T1 Mom Visit: Pets and Pesticide Use
PP001. Now I’d like to ask about any pets you may have in your home.
PP002. Are there any pets that spend any time inside your home?
YES 1
NO 2 (PP008)
REFUSED 9--97 (PP008)
DON’T KNOW 9--98 (PP008)
PP003. What kind of pets are these?
SELECT ALL THAT APPLY.
DOG 1
CAT 2
SMALL
MAMMAL (RABBIT, GERBIL, HAMSTER, GUINEA PIG,
FERRET, MOUSE) 3
BIRD 4
FISH OR REPTILE (TURTLE, SNAKE, LIZARD) 5
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
PP004. Are any products ever used on your pets to control fleas, ticks, or mites? This includes flea collars, flea and tick powders, shampoos, or other flea, tick and mite control products. (This does not include pills given to your pet to control for fleas or other insects.)
YES 1
NO 2 (PP008)
REFUSED 9--97 (PP008)
DON’T KNOW 9--98 (PP008)
PP005. When were any of these last used on any of your pets?
Within the last month, 1
1-3 months ago, 2
4-6 months ago, or 3
More than 6 months ago? 4 (PP008)
REFUSED 9--97 (PP008)
DON’T KNOW 9--98 (PP008)
PP006. What are the names of the products used on your pets to control fleas, ticks, or mites? Please show me the products or containers if you have them.
_____________________________________________________
ENTER PRODUCT NAME FROM LIST
REFUSED 9--97
DON’T KNOW 9--98
PP007. Did you personally handle or apply any of these products to your pets?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
PP008. I would now like to ask about products that may have ever been used in your home or yard to control for ants, termites, cockroaches, bees, wasps, moths, or other insects during the past six months.
PP009. When were any pesticides last used inside or outside this residence to control for insects?
Within the last month, 1
1-3 months ago, 2
4-6 months ago, 3
More than 6 months ago, or 4 (EOS)
Never? 5 (EOS)
REFUSED 9--97 (EOS)
DON’T KNOW 9--98 (EOS)
PP010. In preparation for this interview, we asked that you gather together any of the pesticide cans or containers you may have used in the last 6 months. You may also have letters from building maintenance about pesticide application, or receipts from the exterminator that list which products were used. Please show me, or tell me the names of the products that have been used within the last 6 months, either indoors or outdoors, to treat for insects?
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT, LETTER, OR RECEIPT IS PROVIDED.
_____________________________________________________
PRODUCT NAME FROM LIST
_____________________________________________________
REGISTRATION NUMBER IF KNOWN
REFUSED 9--97 (EOS)
DON’T KNOW 9--98 (EOS)
BEGIN LOOP PP01
LOOP:
|
PP011. How was the {PRODUCT} applied?
SELECT ALL THAT APPLY.
INTERVIEWER INSTRUCTION:
SELECT WITHOUT ASKING IF PRODUCT IS PROVIDED.
SPRAY 01
BOMB 02
POWDER 03
STRIP 04
MOTH BALLS 05
FOAM 06
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
PP012. Which of the following areas of your home were treated with {PRODUCT}? Was it…
YES NO RF DK
a. The
common living area, that is the room other than bedroom or
kitchen
where you spend most of your time? 1 2 9--97 9--98
b. The kitchen? 1 2 9--97 9--98
c. Your bedroom? 1 2 9--97 9--98
d. The basement? 1 2 9--97 9--98
e. Any other rooms? 1 2 9--97 9--98
f. Outdoors, around the walls of your house or building? 1 2 9--97 9--98
g. Outdoors, in the garden or yard? 1 2 9--97 9--98
h. Common
areas inside building but outside of your home or
apartment
(public foyer or hallway, etc.)? 1 2 9--97 9--98
PP013. Who applied the {PRODUCT}? Was it….
You, 1
A professional exterminator, or 2
Someone else? 3
REFUSED 9--97
DON’T KNOW 9--98
PP014. How often was the {PRODUCT} used in the past six months?
More than once a month, or 1
Once a month or less? 2
REFUSED 9--97
DON’T KNOW 9--98
BOX PP03
CHECK ITEM:
|
PP015. When you applied the {PRODUCT}, did you usually wear any protective items such as gloves or a mask?
YES 1
NO 2 (EL_PP01)
REFUSED 9--97 (EL_PP01)
DON’T KNOW 9--98 (EL_PP01)
PP016. Which protective items did you wear?
SELECT ALL THAT APPLY.
GLOVES 1
MASK 2
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
END LOOP PP01
LOOP:
|
T1 Mom Visit: Occupational/Hobby Exposures
OH001. Now I would like to ask some questions about any schoolwork, jobs, volunteer work, and hobbies that you have done recently. Please only include activities that you do or have done for at least four hours per week.
OH002. Are you currently a full- or part-time student? This includes vocational or technical schooling that may not be done in a classroom.
PROBE: Do you go full-time or part-time?
NO, NOT A STUDENT 1 (OH007)
YES, FULL-TIME STUDENT 2
YES, PART-TIME STUDENT 3
REFUSED 9--97 (OH007)
DON’T KNOW 9--98 (OH007)
OH003. What type or types of school are you currently attending?
HIGH SCHOOL 1
TECHNICAL SCHOOL 2
COLLEGE OR UNIVERSITY 3
GRADUATE SCHOOL 4
PROFESSIONAL SCHOOL (E.G., MEDICAL, LAW, DENTAL) 5
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
OH004. Please refer to this card and tell me, what best describes the place where you typically go to school?
PROBE: Is this indoors or outdoors?
SHOW CARD OH1.
SELECT ALL THAT APPLY.
CLASSROOM 01
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S HOME 02
LABORATORY 03
GARAGE OR SHOP 04
MOTOR VEHICLE 05
SOME OTHER LOCATION (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
OH005. What is the address where you actually attend school most often?
HOME 1 (OH007)
VARIES (CONSTRUCTION, LANDSCAPING) 2 (OH007)
HAVE EXACT ADDRESS 3
OTHER (SPECIFY): 6 (OH007)
REFUSED 9--97 (OH007)
DON’T KNOW 9--98 (OH007)
OH006. (Please tell me the address where you actually attend school most often.)
_____________________________________________________
NAME OF SCHOOL
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___| |___|___|___|___|___|
STATE ZIP CODE
REFUSED 9--97
DON’T KNOW 9--98
OH007. Now I would like to ask you about jobs you have had recently.
Since you became pregnant,
NUMBER RF DK
a. How many full-time jobs have you had? |___|___| 9--97 9--98
b. How many part-time jobs have you had? |___|___| 9--97 9--98
c. How
many volunteer jobs have you had (fire department,
humane
society, etc.)? |___|___| 9--97 9--98
BOX OH01
CHECK ITEM:
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BOX OH02
CHECK ITEM:
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BEGIN LOOP OH01
LOOP:
|
BOX OH03
CHECK ITEM:
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OH008. {Now I’d like to ask some questions about each one of your paid or volunteer jobs, starting with the job where you work the most hours/ Now think about the job where you work the next greatest number of hours}”.
OH009. Are you currently employed at this job?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
OH010. For this job, what {is/was} your job title or occupation?
_____________________________________________________
JOB TITLE
REFUSED 9--97
DON’T KNOW 9--98
OH011. For this job, who {is/was} your employer?
_____________________________________________________
EMPLOYER
REFUSED 9--97
DON’T KNOW 9--98
OH012. What types of activities {do/did} you do most often at this job? For example, teach classes, work on the computer, keep account books, file, photocopy, answer phone, wait tables, help customers, do lab work, or carpentry?
PROBE: Anything else?
_____________________________________________________
ACTIVITY
REFUSED 9--97
DON’T KNOW 9--98
OH013. In what kind of business or industry {is/was} this job? That is, what does this company make or do?
_____________________________________________________
INDUSTRY
REFUSED 9--97
DON’T KNOW 9--98
OH014. On average, how many hours a week {do/did} you usually work at this job?
|___|___|___|
NUMBER OF HOURS
REFUSED 9--97
DON’T KNOW 9--98
OH015. {Does/Did} this include working a shift that {starts/started} after 2 pm?
YES 1
NO 2
SOMETIMES 3
REFUSED 9--97
DON’T KNOW 9--98
OH016. {Do/Did} you rotate among different shifts for this job?
YES 1
NO 2
SOMETIMES 3
REFUSED 9--97
DON’T KNOW 9--98
OH017. Please look at this card and tell me, what best describes the place where you typically {work/worked} for this job?
PROBE: Is this indoors or outdoors?
SHOW CARD OH2.
SELECT ALL THAT APPLY.
OFFICE AREA 01
STORE 02
CLASSROOM 03
HOTEL OR MOTEL 04
RESTAURANT 05
RESIDENCE, SUCH AS YOUR HOME OR SOMEONE ELSE’S HOME 06
HEALTHCARE FACILITY OR HOSPITAL 07
LABORATORY 08
FACTORY, PLANT, OR PRODUCTION AREA 09
WAREHOUSE 10
GARAGE OR SHOP 11
SALON 12
LOADING DOCK 13
CONSTRUCTION SITE 14
GROUNDS, YARD, OR GARDEN 15
BARNS, FIELD, OR FARMYARDS 16
MOTOR VEHICLE 17
SOME OTHER LOCATION (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
OH018. What is the address where you actually {work/worked} at this job?
HOME 1 (EL_OH01)
VARIES (CONSTRUCTION, LANDSCAPING) 2 (EL_OH01)
HAVE EXACT ADDRESS 3
OTHER (SPECIFY): 6 (EL_OH01)
REFUSED 9--97 (EL_OH01)
DON’T KNOW 9--98 (EL_OH01)
OH019. Please tell me the address where you actually {work/worked} at this job.
_____________________________________________________
STREET ADDRESS
_____________________________________________________
CITY
|___|___| |___|___|___|___|___|
STATE ZIP CODE
REFUSED 9--97
DON’T KNOW 9--98
END LOOP OH01
LOOP:
|
OH020. Now I want to ask about any cleaning products, chemicals, pesticides, radiation, or bacteria or viruses that you may have worked around or used since you became pregnant at any job, school, or hobby. When answering these questions, please consider all jobs, schools, and hobbies that you do for at least 4 hours per week. Do not include regular household use.
BEGIN LOOP OH02
LOOP:
|
OH021. (In any {full or part-time job,} {volunteer job,} {school,} {or} hobby have you used or worked around):
any {cleaning products, such as bleach, ammonia, or detergents/chemicals, such as paints, fuels, solvents, oils, glues, or hair or nail products/pesticides that you’ve mixed or applied/dusts, including wood or mining dust/fumes or gases, such as from anesthetic gases, ethylene oxide, welding or asphalt fumes, or engine exhaust/radiation, including x-rays, fluoroscopy, or radioisotopes/bacteria or viruses, such as those used in a laboratory setting}?
(Again, do not include regular household use.)
YES 1
NO 2 (EL_OH02)
REFUSED 9--97 (EL_OH02)
DON’T KNOW 9--98 (EL_OH02)
OH022. Please tell me the name of (or describe) the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/bacteria or viruses}?
_____________________________________________________
NAME OR DESCRIPTION OF EXPOSURE
REFUSED 9--97
DON’T KNOW 9--98
OH023. Do
you handle or work directly with the {cleaning
products/chemicals/pesticides/dusts/fumes or
gases/radiation/
bacteria or viruses} or do you just work around
it?
DON’T WORK DIRECTLY WITH THE MATERIAL 1
HANDLE DIRECTLY (POUR, TOUCH, ETC.) 2
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
OH024. Now thinking of the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/bacteria or viruses} that you just mentioned….
OH025. Since you became pregnant, how often did you wear or use personal protective equipment to protect yourself from the {cleaning products/chemicals/pesticides/dusts/fumes or gases/radiation/bacteria or viruses}? By personal protective equipment, I mean things like gloves, dust masks, goggles, aprons, lab coats, or other protective clothing. Would you say you always, often, rarely, or never use personal protective equipment?
ALWAYS 1
OFTEN 2
RARELY 3
NEVER 4 (OH028)
REFUSED 9--97 (OH028)
DON’T KNOW 9--98 (OH028)
OH026. Please look at this card and tell me which types of protective clothing or equipment have you worn?
PROBE: Any other protective clothing or equipment?
SHOW CARD OH3.
SELECT ALL THAT APPLY.
GLOVES 01
OVERALLS 02
OVERCOAT (E.G., LAB COAT, SMOCK, APRON) 03
DUST MASK 04
RESPIRATOR 05
GOGGLES/SAFETY GLASSES/FACE SHIELD 06
WORK BOOTS/SHOES 09
LEAD APRON 08
SOMETHING ELSE (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
OH027. What type of respirator was it?
A
half-mask chemical cartridge respirator, which is silicone or rubber
and covers your mouth and nose, 1
A
full-mask chemical cartridge respirator, which is silicone or rubber
and covers your eyes, nose, and mouth, 2
An air-supplied or SCBA respirator, or 3
Some other kind of respirator? (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
OH028. Is there any kind of a ventilation system to remove exhaust, dust, smoke or fumes from the area? By ventilation system we mean purposely opening windows or doors, using a fume hood, or other ventilation system.
YES 1
NO 2 (EL_OH02)
REFUSED 9--97 (EL_OH02)
DON’T KNOW 9--98 (EL_OH02)
OH029. What ventilation systems are present to remove exhaust, dust, smoke or fumes from the area? Is there….
SELECT ALL THAT APPLY.
General ventilation, meaning open doors or windows, fans, etc 01
A regular HVAC system for building and room heating and cooling, 02
A fume hood, lab hood, or other partially enclosed equipment, 03
A glove box or other totally enclosed equipment, 04
A
portable exhaust hose or tube, such as those used for welding or to
attach to vehicle tailpipe, or 05
Some other type of ventilation system? (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
END LOOP OH02
LOOP:
|
T1 Mom Visit: Commuting
CO001. Next, I’ll be asking about commuting and how you travel from place to place.
CO002. Think of the longest regular commute that you take, to work, school, or elsewhere. By regular commute, I mean someplace that you travel to at least 3 days a week. Since you became pregnant, how do you normally get to your destination?
SELECT ALL THAT APPLY.
DOES NOT HAVE A REGULAR COMMUTE 0 (CO004)
CAR 1
BUS 2
TRAIN, SUBWAY, RAIL, OR LIGHT RAIL 3
WALK, BIKE (NON-MOTORIZED) 4
OTHER (SPECIFY): 6 (CO004)
REFUSED 9--97 (CO004)
DON’T KNOW 9--98 (CO004)
CO003. About how many minutes is this commute, one way? Be sure to include any routine side trips you make on the way, such as stops at day care or school. Include only the time spent driving or sitting inside the car.
|___|___|___|
NUMBER OF MINUTES
REFUSED 9--97
DON’T KNOW 9--98
CO004. Since you became pregnant, how do you normally get to other places, for example, shopping, doctor, visiting friends, or church?
SELECT ALL THAT APPLY.
CAR 1
BUS 2
TRAIN, SUBWAY, RAIL, OR LIGHT RAIL 3
WALK, BIKE (NON-MOTORIZED) 4
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
CO005. Next, I’d like to find out about how often you pump gasoline.
CO006. Since you became pregnant, about how often have you pumped or poured gasoline into a car, truck, motorcycle, other motor vehicle, lawnmower, or other engine:
Every day, 01
4-6 times per week, 02
2-3 times per week, 03
Once a week, 04
One to three times a month, 05
Less than once a month, or 06
Never? 07
REFUSED 9--97
DON’T KNOW 9--98
T1 Mom Visit: Perceived Stress
SD001. The following questions ask about your feelings and thoughts during the last month. Please look at this card and tell me how often you felt or thought a certain way.
SD002. In the last month, how often have you been upset because of something that happened unexpectedly?
SHOW CARD SD1.
Never, 1
Almost never, 2
Sometimes, 3
Fairly often, or 4
Very often? 5
REFUSED 9--97
DON’T KNOW 9--98
SD003. In the last month, how often have you felt that you were unable to control the important things in your life?
SHOW CARD SD1.
NEVER 1
ALMOST NEVER 2
SOMETIMES 3
FAIRLY OFTEN 4
VERY OFTEN 5
REFUSED 9--97
DON’T KNOW 9--98
SD004. (In the last month,) how often have you felt nervous and “stressed”?
SHOW CARD SD1.
NEVER 1
ALMOST NEVER 2
SOMETIMES 3
FAIRLY OFTEN 4
VERY OFTEN 5
REFUSED 9--97
DON’T KNOW 9--98
SD005. (In the last month,) how often have you felt confident about your ability to handle your personal problems?
SHOW CARD SD1.
NEVER 1
ALMOST NEVER 2
SOMETIMES 3
FAIRLY OFTEN 4
VERY OFTEN 5
REFUSED 9--97
DON’T KNOW 9--98
SD006. (In the last month,) how often have you felt that things were going your way?
SHOW CARD SD1.
NEVER 1
ALMOST NEVER 2
SOMETIMES 3
FAIRLY OFTEN 4
VERY OFTEN 5
REFUSED 9--97
DON’T KNOW 9--98
SD007. (In the last month,) how often have you found that you could not cope with all the things that you had to do?
SHOW CARD SD1.
NEVER 1
ALMOST NEVER 2
SOMETIMES 3
FAIRLY OFTEN 4
VERY OFTEN 5
REFUSED 9--97
DON’T KNOW 9--98
SD008. (In the last month,) how often have you been able to control irritations in your life?
SHOW CARD SD1.
NEVER 1
ALMOST NEVER 2
SOMETIMES 3
FAIRLY OFTEN 4
VERY OFTEN 5
REFUSED 9--97
DON’T KNOW 9--98
SD009. (In the last month,) how often have you felt you were on top of things?
SHOW CARD SD1.
NEVER 1
ALMOST NEVER 2
SOMETIMES 3
FAIRLY OFTEN 4
VERY OFTEN 5
REFUSED 9--97
DON’T KNOW 9--98
SD010. (In the last month,) how often have you been angered because of things that were outside of your control?
SHOW CARD SD1.
NEVER 1
ALMOST NEVER 2
SOMETIMES 3
FAIRLY OFTEN 4
VERY OFTEN 5
REFUSED 9--97
DON’T KNOW 9--98
SD011. (In the last month,) how often have you felt difficulties were piling up so high that you could not overcome them?
SHOW CARD SD1.
NEVER 1
ALMOST NEVER 2
SOMETIMES 3
FAIRLY OFTEN 4
VERY OFTEN 5
REFUSED 9--97
DON’T KNOW 9--98
SD012. QUESTION DELETED
SD013. QUESTION DELETED
SD014. QUESTION DELETED
SD015. QUESTION DELETED
SD016. QUESTION DELETED
SD017. QUESTION DELETED
SD018. QUESTION DELETED
SD019. QUESTION DELETED
SD020. QUESTION DELETED
SD021. QUESTION DELETED
SD022. QUESTION DELETED
SD023. QUESTION DELETED
SD024. QUESTION DELETED
SD025. QUESTION DELETED
SD026. QUESTION DELETED
SD027. QUESTION DELETED
SD028. QUESTION DELETED
SD029. QUESTION DELETED
SD030. QUESTION DELETED
SD031. QUESTION DELETED
SD032. QUESTION DELETED
SD033. QUESTION DELETED
T1 Mom Visit: Maternal Depression
MD001. Now, I will read a list of the ways you might have felt or behaved. Please look at this card, and tell me how often you have felt this way during the past week.
SHOW CARD MD1.
MD002. I was bothered by things that usually don’t bother me.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD003. I did not feel like eating; my appetite was poor.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD004. I felt that I could not shake off the blues even with help from my family or friends.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD005. I felt that I was just as good as other people.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD006. I had trouble keeping my mind on what I was doing.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD007. I felt depressed.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD008. I felt that everything I did was an effort.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD009. I felt hopeful about the future.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD010. I thought my life had been a failure.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD011. I felt fearful.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD012. My sleep was restless.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD013. I was happy.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD014. I talked less than usual.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD015. I felt lonely.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD016. People were unfriendly.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD017. I enjoyed life.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD018. I had crying spells.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD019. I felt sad.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD020. I felt that people dislike me.
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
MD021. I could not get “going.”
SHOW CARD MD1.
RARELY OR NONE OF THE TIME (LESS THAN ONE DAY) 1
SOME OR A LITTLE OF THE TIME (1-2 DAYS) 2
OCCASIONALLY OR A MODERATE AMOUNT OF TIME (3-4 DAYS) 3
MOST OR ALL OF THE TIME (5-7 DAYS) 4
REFUSED 9--97
DON’T KNOW 9--98
T1 Mom Visit: Social Support
SS001. QUESTION DELETED
SS002. QUESTION DELETED
SS003. QUESTION DELETED
SS004. QUESTION DELETED
SS005. QUESTION DELETED
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SS008. QUESTION DELETED
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SS011. QUESTION DELETED
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SS018. QUESTION DELETED
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SS025. QUESTION DELETED
SS026. QUESTION DELETED
SS027. QUESTION DELETED
SS028. QUESTION DELETED
SS029. QUESTION DELETED
SS030. For the following questions, please refer to the card and choose the answer that best describes your life now.
SS031. Is there someone available to you whom you can count on to listen to you when you nee to talk:
SHOW CARD SS1.
None of the time, 1
A little of the time, 2
Some of the time, 3
Most of the time, or 4
All of the time? 5
REFUSED 9--97
DON'T KNOW 9--98
SS032. Is there someone available to give you good advice about a problem?
SHOW CARD SS1.
NONE OF THE TIME 1
A LITTLE OF THE TIME 2
SOME OF THE TIME 3
MOST OF THE TIME 4
ALL OF THE TIME 5
REFUSED 9--97
DON'T KNOW 9--98
SS033. Is there someone available to you who shows you love and affection?
SHOW CARD SS1.
NONE OF THE TIME 1
A LITTLE OF THE TIME 2
SOME OF THE TIME 3
MOST OF THE TIME 4
ALL OF THE TIME 5
REFUSED 9--97
DON'T KNOW 9--98
SS034. Is there someone available to help you with daily chores?
SHOW CARD SS1.
NONE OF THE TIME 1
A LITTLE OF THE TIME 2
SOME OF THE TIME 3
MOST OF THE TIME 4
ALL OF THE TIME 5
REFUSED 9--97
DON'T KNOW 9--98
SS035. Can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?
SHOW CARD SS1.
NONE OF THE TIME 1
A LITTLE OF THE TIME 2
SOME OF THE TIME 3
MOST OF THE TIME 4
ALL OF THE TIME 5
REFUSED 9--97
DON'T KNOW 9--98
SS036. Do you have as much contact as you would like with someone you feel close to, someone in whom you can trust and confide?
SHOW CARD SS1.
NONE OF THE TIME 1
A LITTLE OF THE TIME 2
SOME OF THE TIME 3
MOST OF THE TIME 4
ALL OF THE TIME 5
REFUSED 9--97
DON'T KNOW 9--98
T1 Mom Visit: Household Composition and Demographics: Part 2
DM001. These next questions are about your background and cultural heritage.
DM002. Were you born in the United States?
YES 1 (DM005)
NO 2
REFUSED 9--97 (DM005)
DON’T KNOW 9--98 (DM005)
DM003. In what country were you born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED 9--97
DON’T KNOW 9--98
DM004. About how long have you lived in the United States?
INTERVIEWER INSTRUCTION:
IF LESS THAN ONE YEAR, ENTER ”00”.
|___|___|
YEARS
REFUSED 9--97
DON’T KNOW 9--98
DM005. Was your mother born in the United States?
YES 1 (DM007)
NO 2
REFUSED 9--97 (DM007)
DON’T KNOW 9--98 (DM007)
DM006. In what country was your mother born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED 9--97
DON’T KNOW 9--98
DM007. Was your father born in the United States?
YES 1 (DM009)
NO 2
REFUSED 9--97 (DM009)
DON’T KNOW 9--98 (DM009)
DM008. In what country was your father born?
INTERVIEWER INSTRUCTION:
SELECT COUNTRY FROM LIST.
(Source: U.S. State Department List, Independent States in the World)
REFUSED 9--97
DON’T KNOW 9--98
DM009. These next questions are about the food eaten in your household in the last 12 months, and whether you were able to afford the food you need.
DM010. QUESTION DELETED
DM011. QUESTION DELETED
DM011a. I’m going to read you two statements that people have made about their food situation. Please tell me whether the statement was OFTEN, SOMETIMES, or NEVER true for {you/you and the other members of your household} in the last 12 months.
The first statement is “The food that {I/we} bought just didn’t last, and {I/we} didn’t have money to get more.” Was that often, sometimes, or never true for {you/your household} in the last 12 months?
OFTEN TRUE 1
SOMETIMES TRUE 2
NEVER TRUE 3
REFUSED 9--97
DON'T KNOW 9--98
DM011b. “{I/We} couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for {you/your household} in the last 12 months?
OFTEN TRUE 1
SOMETIMES TRUE 2
NEVER TRUE 3
REFUSED 9--97
DON'T KNOW 9--98
DM011c. In the last 12 months, did {you/you or the other adults in your household} ever cut the size of your meals or skip meals because there wasn’t enough money for food?
YES 1
NO 2
REFUSED 9--97
DON'T KNOW 9--98
BOX DM01
CHECK ITEM:
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BOX DM02
CHECK ITEM:
|
DM011d. How often did this happen – almost every month, some months but not every month, or in only 1 or 2 months?
ALMOST EVERY MONTH 1
SOME MONTHS BUT NOT EVERY MONTH 2
ONLY 1 OR 2 MONTHS 3
REFUSED 9--97
DON'T KNOW 9--98
DM011e. In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money to buy food?
YES 1
NO 2
REFUSED 9--97
DON'T KNOW 9--98
DM011f. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford enough food?
YES 1
NO 2
REFUSED 9--97
DON'T KNOW 9--98
DM012. Now I’m going to switch the subject and ask about health insurance.
DM013. Do you currently have insurance through a current or former employer or union either through yourself or another family member?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM014. (Do you currently have:)
Insurance purchased directly from an insurance company (by yourself or another family member)?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM015. (Do you currently have:)
Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM016. (Do you currently have:)
TRICARE, VA, or other military health care?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM017. (Do you currently have:)
Indian Health Service?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM018. (Do you currently have:)
Medicare, for people 65 and older, or people with certain disabilities?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM019. (Do you currently have:)
Any other type of health insurance or health coverage plan?
YES (SPECIFY): 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
DM020. Lastly, I’d like to find out how you see yourself in relation to other people in the United States.
DM021. Please look at this card. Think of this ladder as representing where people stand in the United States. At the top of the ladder are the people who are the best off – those who have the most money, the most education and the most respected jobs. At the bottom are the people who are the worst off – who have the least money, least education, and the least respected jobs or no job.
Where would you place yourself on this ladder?
Please point to the rung where you think you stand at this time in your life, relative to other people in the United States.
SHOW CARD DM1.
RUNG A 01
RUNG B 02
RUNG C 03
RUNG D 04
RUNG E 05
RUNG F 06
RUNG G 07
RUNG H 08
RUNG I 09
RUNG J 10
REFUSED 9--97
DON’T KNOW 9--98
T1 Mom Visit: ACASI
AI001. These next questions may be somewhat sensitive. Like all of the other questions that you have answered today, your response will be kept confidential. If you are not sure about an answer, give us your best estimate. If you’d like you can listen to the questions using headphones and enter your information directly into the computer. You can also listen to the questions without headphones or I can read the questions to you.
Which would you prefer? Would you like to:
Listen to the questions on your own using headphones, 1
Listen to the questions on your own without headphones, or 2
Have me read the questions to you? 3 (EOS)
AI002. As part of an earlier interview, you may have completed some questions like this on your own. Would you like to do the practice questions this time, or would you like to go right ahead to the interview?
DO PRACTICE QUESTIONS 1
GO TO INTERVIEW 2
T1 Mom Visit: ACASI Practice
AP001. The first two questions are practice questions and are not part of the study. They will help you learn how to use this computer. Remember that you need to press the ‘NEXT’ button after you have answered each question. If at any time you make a mistake answering a question, you can press the ‘CLEAR’ button to erase your answer and then select the correct answer. Press “NEXT” to see the first practice question.
AP002. What is your favorite soft drink?
Coke 1
Pepsi 2
Sprite 3
7-Up 4
Another soft drink 5
REFUSED 9--97
DON’T KNOW 9--98
AP003. During a typical week, how many movies do you watch?
|___|___|
NUMBER OF MOVIES
REFUSED 9--97
DON’T KNOW 9--98
AP004. You have now completed the practice questions and are ready to begin the study questions. If at any point, you don’t know the answer to a question or prefer not to answer, press the “NEXT” button without selecting an answer and follow the computer’s instructions. Let your interviewer know if you need help while answering the questions on your own.
Please put on the headphones now. Your interviewer will help you adjust the volume. When you are ready, press ‘NEXT’ to see the first question.
T1 Mom Visit: ACASI Reproductive History (RH)
RH001. I’ll begin by asking about your current pregnancy.
RH002. Regarding this pregnancy, were you trying to become pregnant?
Yes 1
No 2 (RH004)
REFUSED 9--97 (RH004)
DON’T KNOW 9--98 (RH004)
RH003. For about how many months were you trying to become pregnant? If 1 month or less, enter 1.
|___|___|
MONTHS
REFUSED 9--97
DON’T KNOW 9--98
RH004. Were you using birth control when you became pregnant?
Yes 1
No 2 (RH006)
REFUSED 9--97 (RH006)
DON’T KNOW 9--98 (RH006)
RH005. When you became pregnant, what were you using? You may select more than one answer. Did you use birth control pills, use a condom, use Depo-Provera or other shots or injections, use Natural family planning, including rhythm or safe period by calendar, temperature, or cervical mucus, use a diaphragm, cervical cap or shield, use foam, jelly, cream, a suppository or other insert, use a female condom or vaginal pouch, use the patch, Norplant, the ring or Nuva ring, use a TODAY® sponge, use an IUD, coil or loop, use Plan B or the “Morning After” pill, use withdrawal or “pulling out” or did you use some other method or do something else?
Birth control pills 1
Condoms 2
Depo-Provera/shots/injections 3
Natural family planning 4
Diaphragm/cap/shield 5
Foam/jelly/cream/insert 6
Female condom/vaginal pouch 7
Patch/Norplant/Nuva ring 8
TODAY® sponge 9
IUD/Coil/Loop 10
Plan B/“Morning After” pill 11
Withdrawal/pulling out 12
Some other method 96
REFUSED 9--97
DON’T KNOW 9--98
RH006. When you became pregnant, did you yourself actually want to have a baby at some time?
Yes 1
No 2 (RH008)
REFUSED 9--97 (RH008)
DON’T KNOW 9--98 (RH008)
RH007. So would you say you became pregnant too soon, at about the right time, or later than you wanted?
Too soon 1
Right time 2
Later 3
Didn’t care 4
REFUSED 9--97
DON’T KNOW 9--98
RH008. How tall are you without shoes?
|___|
NUMBER OF FEET
REFUSED 9--97
DON’T KNOW 9--98
RH08A. How tall are you without shoes?
RESPONDENT INSTRUCTION:
Using the keypad, enter the number of inches.
|___|___|
NUMBER INCHES
REFUSED 9--97
DON’T KNOW 9--98
RH009. What was your weight just before you became pregnant?
First, select whether you would like to enter in pounds or kilograms. Press “NEXT” when you are done.
POUNDS 1
KILOGRAMS 2 (RH09B)
REFUSED 9--97 (RH010)
DON’T KNOW 9--98 (RH010)
RH09A. What was your weight just before you became pregnant?
Using the keypad, enter the number of pounds. Press “NEXT” when you are done.
|___|___|___|
WEIGHT IN POUNDS
REFUSED 9--97
DON’T KNOW 9--98
RH09B. What was your weight just before you became pregnant?
Using the keypad, enter the number of kilograms. Press “NEXT” when you are done.
|___|___|___|.|___|
WEIGHT IN KILOGRAMS
REFUSED 9--97
DON’T KNOW 9--98
RH010. Some women use a cleansing method known as douching. By douching, we mean putting a substance into your vagina for medicinal or hygienic purposes.
RH011. Since you became pregnant, how often on average have you douched?
Never 01
Less than once a month 02
1-3 times a month 03
Once a week 04
2-4 times a week, 05
5 or more times a week 06
REFUSED 9--97
DON’T KNOW 9--98
RH012. These next questions are about your reproductive history. I’ll begin by asking about your periods or menstrual cycle.
RH013. How old were you when you had your first menstrual period?
|___|___| (RH015)
AGE
REFUSED 9--97 (RH015)
DON’T KNOW 9--98
RH014. What grade were you in when you had your first menstrual period?
|___|___|
GRADE
REFUSED 9--97
DON’T KNOW 9--98
RH015. These next questions are about any previous pregnancies you may have had.
RH016. Before this pregnancy, have you ever been pregnant? Please include live births, miscarriages, stillbirths, ectopic pregnancies, abortions and pregnancy terminations.
Yes 1
No 2 (EOS)
REFUSED 9--97 (EOS)
DON’T KNOW 9--98 (EOS)
RH017. How old were you when you became pregnant for the first time?
|___|___|
AGE
REFUSED 9--97
DON’T KNOW 9--98
RH018. In what month and year did your most recent pregnancy end?
Using the keypad, enter the month your most recent pregnancy ended. Press “NEXT” to enter the year.
|___|___|
MONTH
REFUSED 9--97 (RH019)
DON’T KNOW 9--98
RH018A. Using the keypad, enter the year your most recent pregnancy ended. Press “NEXT” when you are done.
|___|___|___|___|
YEAR
REFUSED 9--97
DON’T KNOW 9--98
RH019. Not including your current pregnancy, how many times have you been pregnant?
|___|___|
NUMBER OF PREGNANCIES
REFUSED 9--97
DON’T KNOW 9--98
RH020. How many of your pregnancies resulted in a live birth?
I___I___I
NUMBER
REFUSED 9--97
DON’T KNOW 9--98
RH021. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health care provider that you had:
Diabetes?
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
RH022. QUESTION DELETED
RH023. QUESTION DELETED
RH024. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health care provider that you had:
Preeclampsia or toxemia?
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
RH025. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health care provider that you had:
Early or premature labor?
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
RH026. QUESTION DELETED
RH027. QUESTION DELETED
RH028. QUESTION DELETED
RH029. QUESTION DELETED
RH030. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health care provider that you had:
Bacterial vaginosis?
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
RH031. QUESTION DELETED
RH032. QUESTION DELETED
RH033. During {your previous pregnancy/any of your previous pregnancies}, were you told by a doctor or other health care provider that you had:
Any other serious condition?
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
BOX RH01
CHECK ITEM:
|
RH034. How many of your biological children are still living?
|___|___|
NUMBER
REFUSED 9--97 (RH037)
DON’T KNOW 9--98 (RH037)
RH035. Were any of these children born with a birth defect or inherited disease or condition?
Yes 1
No 2 (RH037)
REFUSED 9--97 (RH037)
DON’T KNOW 9--98 (RH037)
RH036. What birth defects or conditions were they born with? You may select more than one answer.
Congenital heart defect 01
Cleft lip or palate 02
Any neural tube defect 03
Any abdominal defect 04
Hypospadias 05
Any limb defect 06
Down syndrome 07
Cystic fibrosis 08
Pyloric stenosis 09
Sickle cell disease 10
Fetal alcohol syndrome 11
Other condition or defect 96
REFUSED 9--97
DON’T KNOW 9--98
RH037. Have you ever had any children who were born alive but died later?
Yes 1
No 2 (RH042)
REFUSED 9--97 (RH042)
DON’T KNOW 9--98 (RH042)
RH038. How many of your children have died?
|___|___|
NUMBER
REFUSED 9--97
DON’T KNOW 9--98
BEGIN LOOP RH01
|
RH039. How old {were they/was the first child/was the next child} when they died? Please enter the number of days, weeks, months, or years, then select the unit of time. If this child was less than 1 day old, enter “1” and select “Days”.
|___|___|
AGE
DAYS 1
WEEKS 2
MONTHS 3
YEARS 4
REFUSED 9--97
DON’T KNOW 9--98
RH040. What caused their death? You may select more than one answer.
Birth defect 01 (RH041)
Preterm birth 02
Respiratory distress syndrome 03
SIDS 04
Complications from labor and delivery 05
Injury/Injuries 06
Cancer 07
Other 96
REFUSED 9--97
DON’T KNOW 9--98
RH041. What birth defects or conditions were they born with? You may select more than one answer.
Congenital heart defect 01
Any neural tube defect 02
Any abdominal defect 03
Any limb defect 04
Down syndrome 05
Cystic fibrosis 06
Sickle cell disease 07
Fetal alcohol syndrome 08
Other condition or defect 96
REFUSED 9--97
DON’T KNOW 9--98
END LOOP RH01
|
RH042. Have you ever had any miscarriages?
Yes 1
No 2 (RH044)
REFUSED 9--97 (RH044)
DON’T KNOW 9--98 (RH044)
RH043. How many?
|___|___|
NUMBER
REFUSED 9--97
DON’T KNOW 9--98
RH044. Have you ever had a stillborn baby? A stillborn baby is born at 24 weeks or later.
Yes 1
No 2 (RH046)
REFUSED 9--97 (RH046)
DON’T KNOW 9--98 (RH046)
RH045. How many?
|___|___|
NUMBER
REFUSED 9--97
DON’T KNOW 9--98
RH046. How many weeks pregnant were you when {this/the first/the next} baby was stillborn?
|___|___|
NUMBER OF WEEKS
REFUSED 9--97
DON’T KNOW 9--98
RH047. Have you ever had any abortions or other pregnancy terminations, including ectopic or tubal pregnancies?
Yes 1
No 2 (RH049)
REFUSED 9--97 (RH049)
DON’T KNOW 9--98 (RH049)
RH048. How many?
|___|___|
NUMBER
REFUSED 9--97
DON’T KNOW 9--98
BOX RH06
CHECK ITEM:
|
RH049. Were any of your live-born babies born more than 3 weeks early?
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
RH050. Did any of your full-term babies, who were born at 37 weeks or later, weigh less than 5lb 8oz or 2500 grams at birth?
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
RH051. Have you ever had twins, triplets, or other multiple births?
Yes 1
No 2 (RH053)
REFUSED 9--97 (RH053)
DON’T KNOW 9--98 (RH053)
RH052. Were fertility drugs or treatments used to help you conceive that time?
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
RH053. Have you ever had a Cesarean section?
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
T1 Mom Visit: ACASI Drugs, Alcohol and Cigarette Use
DA001. The next questions are about your use of cigarettes and alcohol just before your current pregnancy.
DA002. In the 3 months before you knew you were pregnant, did you smoke any cigarettes or cigarillos?
Yes 1
No 2 (DA005)
REFUSED 9--97 (DA005)
DON’T KNOW 9--98 (DA005)
DA003. Did you smoke cigarettes or cigarillos:
Every day 01
5 or 6 days a week 02
2-4 days a week 03
Once a week 04
1-3 days a month 05
Less than once a month 06
REFUSED 9--97
DON’T KNOW 9--98
DA004. On days that you smoked, how many cigarettes or cigarillos did you smoke per day? If you smoked 1 or less per day, enter “1.”
|___|___|
NUMBER PER DAY
REFUSED 9--97
DON’T KNOW 9--98
DA005. In the 3 months before you knew you were pregnant, did you smoke or use any other tobacco products such as pipes, cigars, chewing tobacco, or snuff?
Yes 1
No 2 (DA008)
REFUSED 9--97 (DA008)
DON’T KNOW 9--98 (DA008)
DA006. What did you use? You may select more than one answer.
Cigars 1
Pipes 2
Chewing tobacco 3
Snuff 4
Other 6
REFUSED 9--97
DON’T KNOW 9--98
DA007. Did you use the other tobacco products:
Every day 01
5 or 6 days a week 02
2-4 days a week 03
Once a week 04
1-3 days a month 05
Less than once a month 06
REFUSED 9--97
DON’T KNOW 9--98
DA008. In the 3 months before you knew you were pregnant, did you use any nicotine patches, gum, or other nicotine products?
Yes 1
No 2 (DA011)
REFUSED 9--97 (DA011)
DON’T KNOW 9--98 (DA011)
DA009. What did you use? You may select more than one answer.
Nicotine patches 1
Nicotine gum 2
Other nicotine product 6
REFUSED 9--97
DON’T KNOW 9--98
DA010. Did you use these other nicotine products:
Every day 01
5 or 6 times a week 02
2-4 times a week 03
Once a week 04
1-3 times a month 05
Less than once a month 06
REFUSED 9--97
DON’T KNOW 9--98
DA011. Currently, do you smoke cigarettes or cigarillos?
Yes 1
No 2 (DA014)
REFUSED 9--97 (DA014)
DON’T KNOW 9--98 (DA014)
DA012. Do you smoke cigarettes or cigarillos:
Every day 01
5 or 6 days a week 02
2-4 days a week 03
Once a week 04
1-3 days a month 05
Less than once a month 06
REFUSED 9--97
DON’T KNOW 9--98
DA013. On days that you smoke, how many cigarettes or cigarillos do you smoke per day? If you smoke 1 or less per day, enter “1.”
|___|___|
NUMBER PER DAY
REFUSED 9--97
DON’T KNOW 9--98
DA014. Currently, do you smoke or use any other tobacco products such as pipes, cigars, chewing tobacco, or snuff?
Yes 1
No 2 (DA017)
REFUSED 9--97 (DA017)
DON’T KNOW 9--98 (DA017)
DA015. What do you use? You may select more than one answer.
Cigars 1
Pipes 2
Chewing tobacco 3
Snuff 4
Other 6
REFUSED 9--97
DON’T KNOW 9--98
DA016. Do you use these other tobacco products:
Every day 01
5 or 6 days a week 02
2-4 days a week 03
Once a week 04
1-3 days a month 05
Less than once a month 06
REFUSED 9--97
DON’T KNOW 9--98
DA017. Currently, do you use nicotine patches, gum, or other nicotine products?
Yes 1
No 2 (DA020)
REFUSED 9--97 (DA020)
DON’T KNOW 9--98 (DA020)
DA018. What do you use? You may select more than one answer.
Nicotine patches 1
Nicotine gum 2
Other nicotine product 6
REFUSED 9--97
DON’T KNOW 9--98
DA019. Do you use these other nicotine products:
Every day 01
5 or 6 days a week 02
2-4 days a week 03
Once a week 04
1-3 days a month 05
Less than once a month 06
REFUSED 9--97
DON’T KNOW 9--98
BOX DA01
CHECK ITEM:
|
DA020. When did you stop smoking cigarettes or cigarillos?
More than 2 weeks before you knew you were pregnant 1
Less than 2 weeks before you knew you were pregnant 2
When you found out you were pregnant 3
After you found out you were pregnant 4
REFUSED 9--97
DON’T KNOW 9--98
BOX DA02
CHECK ITEM:
|
DA021. When did you stop using other tobacco products?
More than 2 weeks before you knew you were pregnant 1
Less than 2 weeks before you knew you were pregnant 2
When you found out you were pregnant 3
After you found out you were pregnant 4
REFUSED 9--97
DON’T KNOW 9--98
DA022. On average, about how many hours per day do people smoke in the same room as you, or near enough that you can see or smell the smoke? Please consider all the places you are during the day, including at home, at work, or some other place. If you are not exposed to smoke, enter “0.”
|___|___|
HOURS
REFUSED 9--97
DON’T KNOW 9--98
DA023. In the 3 months before you knew you were pregnant, how often did you drink alcoholic beverages including wine, beer, drinks containing hard liquor, wine coolers, hard lemonade, or hard cider?
5 or more times a week 01
2-4 times a week 02
Once a week 03
1-3 times a month 04
Less than once a month 05
Never 06 (DA027)
REFUSED 9--97 (DA027)
DON’T KNOW 9--98 (DA027)
DA024. In the 3 months before you knew you were pregnant, on days that you drank alcoholic beverages, how many did you have per day? If you drank one or less enter “1.”
|___|___|
NUMBER OF DRINKS
REFUSED 9--97
DON’T KNOW 9--98
DA025. In the 3 months before you knew you were pregnant, how often did you have 5 or more drinks within a couple of hours:
Never 1
About once a month 2
About once a week 3
About once a day 4
REFUSED 9--97
DON’T KNOW 9--98
DA026. In the 3 months before you knew you were pregnant, on days that you drank alcoholic beverages, what type or types did you drink? You may select more than one answer.
Wine 1
Beer 2
Hard Liquor/Mixed Drinks 3
Wine Coolers 4
Hard Lemonade/Hard Cider 5
Other 6
REFUSED 9--97
DON’T KNOW 9--98
DA027. How often do you currently drink alcoholic beverages?
5 or more times a week 01
2-4 times a week 02
Once a week 03
1-3 times a month 04
Less than once a month 05
Never 06 (BOX DA03)
REFUSED 9--97 (DA032)
DON’T KNOW 9--98 (DA032)
DA028. Currently, on days that you drink alcoholic beverages, how many did you have per day? If you drink 1 or less, enter “1.”
|___|___|
NUMBER OF DRINKS
REFUSED 9--97
DON’T KNOW 9--98
DA029. Currently, how often do you have 5 or more drinks within a couple of hours:
Never 1
About once a month 2
About once a week 3
About once a day 4
REFUSED 9--97
DON’T KNOW 9--98
DA030. Currently, on days that you drink alcoholic beverages, what type or types did you drink? You may select more than one answer.
Wine 1
Beer 2
Hard Liquor/Mixed Drinks 3
Wine Coolers 4
Hard Lemonade/Hard Cider 5
Other 6
REFUSED 9--97
DON’T KNOW 9--98
BOX DA03
|
DA031. When did you stop drinking alcoholic beverages?
More than 2 weeks before you knew you were pregnant 1
Less than 2 weeks before you knew you were pregnant 2
When you found out you were pregnant 3
After you found out you were pregnant 4
REFUSED 9--97
DON’T KNOW 9--98
DA032. The following questions ask about any prescription drugs you used without a doctor’s prescription, in larger amounts than prescribed, or for a longer period than prescribed. This includes your use of any recreational or "street" drugs. Please remember that your answers to these questions are strictly confidential.
DA033. In the 3 months before you knew you were pregnant, did you use any:
Sedatives, including either barbiturates or sleeping pills without a doctor’s prescription, in larger amounts than prescribed, or for a longer period than prescribed? For example, Amytal, Seconal, or Halcion.
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
DA034. In the 3 months before you knew you were pregnant, did you use any:
Tranquilizers or “nerve pills” (without a doctor’s prescription, in larger amounts than prescribed, or for a longer period than prescribed)? For example, Librium, Valium, Ativan, or Xanax.
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
DA035. In the 3 months before you knew you were pregnant, did you use any:
Amphetamines or other stimulants (without a doctor’s prescription, in larger amounts than prescribed, or for a longer period than prescribed)? For example, methamphetamine, Ritalin, Dexedrine, Ecstasy, or speed.
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
DA036. In the 3 months before you knew you were pregnant, did you use any:
Analgesics or other prescription painkillers (without a doctor’s prescription, in larger amounts than prescribed, or for a longer period than prescribed)? This does not include normal use of aspirin or Tylenol without codeine but does include use of Tylenol with codeine, Percocet, Lortab, codeine, OxyContin, oxycodone, morphine, methadone, or other prescription pain killers.
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
DA037. In the 3 months before you knew you were pregnant, did you use any:
Inhalants that you sniff or breathe to get high or to feel good? For example, Amylnitrate, nitrous oxide or “whippets”, glue, gasoline or spray paint.
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
DA038. In the 3 months before you knew you were pregnant, did you use any:
Marijuana or hashish?
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
DA039. In the 3 months before you knew you were pregnant, did you use any:
Cocaine, crack, or free base?
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
DA040. In the 3 months before you knew you were pregnant, did you use any:
LSD or other hallucinogens? For example PCP, angel dust, peyote, or mescaline.
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
DA041. In the 3 months before you knew you were pregnant, did you use:
Heroin?
Yes 1
No 2
REFUSED 9--97
DON’T KNOW 9--98
T1 Mom Visit: ACASI – Family Income
FI001. 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 data you provide is confidential.
FI002. QUESTION DELETED
FI003. QUESTION DELETED
FI004. QUESTION DELETED
FI005. QUESTION DELETED
FI006. QUESTION DELETED
FI007. QUESTION DELETED
FI008. QUESTION DELETED
FI009. QUESTION DELETED
FI010. Of these income groups, which category best represents {your/the total combined family} income during {LAST CALENDAR YEAR}? Remember, a family is a group of two or more people who live together and who are related by birth, marriage, or adoption.
Less than $4,999 01 (FI012)
$5,000-$9,999 02 (FI012)
$10,000-$19,999 03 (FI012)
$20,000-$29,999 04 (FI012)
$30,000-$39,999 05 (FI012)
$40,000-$49,999 06 (FI012)
$50,000-$74,999 07 (FI012)
$75,000-$99,999 08 (FI012)
$100,000-$199,000 09 (FI012)
$200,000 or more 10 (FI012)
REFUSED 9--97
DON’T KNOW 9--98
FI011. Was your total family income in {LAST CALENDAR YEAR} before taxes:
$20,000 or more, or 1
Less than $20,000? 2
REFUSED 9--97
DON’T KNOW 9--98
FI012. Are there any other family members, not living in this household, who are also supported by this income?
Yes 1
No 2 (EOS)
REFUSED 9--97 (EOS)
DON’T KNOW 9--98 (EOS)
FI013. How many other family members, not living in this household, are supported by this income?
|___|___|
NUMBER
REFUSED 9--97
DON’T KNOW 9--98
T1 Mom Visit: ACASI Domestic Abuse
AB001. The following questions are about your physical safety.
AB002. Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by anyone?
Yes 1
No 2 (AB008)
REFUSED 9--97 (AB008)
DON’T KNOW 9--98 (AB008)
AB003. Was this by? You may select more than one answer.
Your husband or partner 1
Your parent 2
Other adult family member 3
Someone you know, but not a family member 4
A stranger 5
REFUSED 9--97
DON’T KNOW 9--98
AB004. How often did this happen?
1 time 1
2-3 times 2
3 or more times 3
REFUSED 9--97
DON’T KNOW 9--98
AB005. Since you’ve been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by anyone?
Yes 1
No 2 (AB008)
REFUSED 9--97 (AB008)
DON’T KNOW 9--98 (AB008)
AB006. Was this by? You may select more than one answer.
Your husband or partner 1
Your parent 2
Other adult family member 3
Someone you know, but not a family member 4
A stranger 5
REFUSED 9--97
DON’T KNOW 9--98
AB007. How often has this happened?
1 time 1
2-3 times 2
3 or more times 3
REFUSED 9--97
DON’T KNOW 9--98
AB008. Thank you for answering these questions. Please let your interviewer know that you are done.
T1 Mom Interview: Tracing Information
BOX TR01
CHECK ITEM: IF CN022h AT CONSENT = “9--97” OR “9--98”, GO TO BOX TR07. OTHERWISE, CONTINUE WITH TR001.
|
TR001. I’d like to confirm the contact information you previously provided of friends or relatives not currently living with you. We may use this information in case we have trouble contacting you in the future.
TR002. Is {NAME} still a good person to contact in case we have trouble reaching you?
YES 1
NO 2 (BOX TR04)
REFUSED 9--97 (BOX TR04)
DON’T KNOW 9--98 (BOX TR04)
BOX TR02
CHECK ITEM: IF CN022k AT CONSENT = “9--97” OR “9--98”, GO TO TR004. OTHERWISE, CONTINUE WITH TR003.
|
TR003. Does {NAME} still live at {STREET} {CITY}, {STATE} {ZIP CODE}?
YES 1 (TR005)
YES WITH CORRECTIONS 2
NO, NEW ADDRESS NEEDED 3
REFUSED 9--97 (TR005)
DON’T KNOW 9--98 (TR005)
TR004. What is {NAME}’s correct address?
INTERVIEWER INSTRUCTIONS:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________________________
STREET
_____________________________________________________
CITY
|___|___| |___|___|___|___|___|
STATE ZIP CODE
REFUSED 9--97
DON’T KNOW 9--98
BOX TR03
CHECK ITEM: IF CN022l AT CONSENT = “9--97” OR “9--98”, GO TO TR006. OTHERWISE, CONTINUE WITH TR005.
|
TR005. Is {NAME}’s telephone number still {PHONE NUMBER}?
YES 1 (BOX TR04)
YES WITH CORRECTIONS 2
NO, NUMBER HAS BEEN CHANGED 3
REFUSED 9--97 (BOX TR04)
DON’T KNOW 9--98 (BOX TR04)
TR006. What is {NAME}’s phone number?
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
NONE 9--91
REFUSED 9--97
DON’T KNOW 9--98
BOX TR04
CHECK ITEM: IF CN022m AT CONSENT = “9--91”, “9--97” OR “9--98”, GO TO BOX TR07. OTHERWISE, CONTINUE WITH TR007.
|
TR007. Is {NAME} still a good person to contact in case we have trouble reaching you?
YES 1
NO 2 (BOX TR07)
REFUSED 9--97 (BOX TR07)
DON’T KNOW 9--98 (BOX TR07)
BOX TR05
CHECK ITEM: IF CN022o AT CONSENT = “9--97” OR “9--98”, GO TO TR009. OTHERWISE, CONTINUE WITH TR008.
|
TR008. Does {NAME} still live at {STREET} {CITY}, {STATE} {ZIP CODE}?
YES 1 (BOX TR06)
YES WITH CORRECTIONS 2
NO, NEW ADDRESS NEEDED 3
REFUSED 9--97 (BOX TR06)
DON’T KNOW 9--98 (BOX TR06)
TR009. What is {NAME}’s correct address?
INTERVIEWER INSTRUCTIONS:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________________________
STREET
_____________________________________________________
CITY
|___|___| |___|___|___|___|___|
STATE ZIP CODE
REFUSED 9--97
DON’T KNOW 9--98
BOX TR06
CHECK ITEM: IF CN022p AT CONSENT = “9--97” OR “9--98”, GO TO TR011. OTHERWISE, CONTINUE WITH TR1000.
|
TR010. Is {NAME}’s telephone number still {PHONE NUMBER}?
YES 1 (BOX TR07)
YES WITH CORRECTIONS 2
NO, NEW PHONE NUMBER 3
REFUSED 9--97 (BOX TR07)
DON’T KNOW 9--98 (BOX TR07)
TR011. What is {NAME}’s phone number?
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
NONE 9--91
REFUSED 9--97
DON’T KNOW 9--98
BOX TR07
CHECK ITEM: IF CN022h = “2”, “9--97”, OR “9--98” FROM CONSENT, OR TR002 = “2” FROM CURRENT INTERVIEW, CONTINUE WITH TR012. OTHERWISE, GO TO BOX TR08.
|
TR012. {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 (TR021)
REFUSED 9--97 (TR021)
DON’T KNOW 9--98 (TR021)
TR013. What is this person’s name?
INTERVIEWER INSTRUCTION:
CONFIRM SPELLING OF FIRST AND LAST NAMES.
______________ __________________
FIRST NAME LAST NAME
REFUSED 9--97 (TR021)
DON’T KNOW 9--98 (TR021)
TR014. What is his/her relationship to you?
MOTHER/FATHER 01
BROTHER/SISTER 02
AUNT/UNCLE 03
GRANDPARENT 04
NEIGHBOR 05
FRIEND 06
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
TR015. What is his/her address?
INTERVIEWER INSTRUCTIONS:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________________________
STREET
_____________________________________________________
CITY
|___|___| |___|___|___|___|___|
STATE ZIP CODE
REFUSED 9--97 (BOX TR08)
DON’T KNOW 9--98
TR016. What is his/her telephone number?
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
NONE 9--91
REFUSED 9--97
DON’T KNOW 9--98
BOX TR08
CHECK ITEM: IF CN022h = “2”, “9--97”, OR “9--98” FROM CONSENT, OR TR007 = “2” FROM CURRENT INTERVIEW, CONTINUE WITH TR017. OTHERWISE, GO TO TR021.
|
TR017. Now I’d like to collect information on a second contact. What is this person’s name?
INTERVIEWER INSTRUCTION:
CONFIRM SPELLING OF FIRST AND LAST NAMES.
______________ __________________
FIRST NAME LAST NAME
NO SECOND CONTACT PROVIDED 9--91 (TR021)
REFUSED 9--97 (TR021)
DON’T KNOW 9--98 (TR021)
TR018. What is his/her relationship to you?
MOTHER/FATHER 01
BROTHER/SISTER 02
AUNT/UNCLE 03
GRANDPARENT 04
NEIGHBOR 05
FRIEND 06
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
TR019. What is his/her address?
INTERVIEWER INSTRUCTIONS:
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________________________
STREET
_____________________________________________________
CITY
|___|___| |___|___|___|___|___|
STATE ZIP CODE
REFUSED 9--97 (BOX TR021)
DON’T KNOW 9--98
TR020. What is his/her telephone number?
|___|___|___|___|___|___|___|___|___|___|
PHONE NUMBER
NONE 9--91
REFUSED 9--97
DON’T KNOW 9--98
TR021. QUESTION DELETED
TR022. Thank you for answering these questions. This completes the interview portion of the visit.
Revised 7/2/08
| File Type | application/msword |
| File Title | T1 Mom Visit: Interview Introduction |
| File Modified | 2008-09-15 |
| File Created | 2008-09-15 |
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