Form 9 Survey

OMB #: 0925-0593

Expiration Date: xx/xxxx

JULY LAUNCH VERSION

VERSION 6/7/2010

Recruitment Strategy Substudy

Low-Intensity CATI Questionnaire

TABLE OF CONTENTS

CATI

INTERVIEWER-COMPLETED QUESTIONS

CURRENT PREGNANCY INFORMATION

MEDICAL HISTORY

HEALTH INSURANCE

HOUSING CHARACTERISTICS

TOBACCO USE AND ALCOHOL

INTERVIEW EVALUATION

CONCLUSION

DOCUMENT HISTORY

DATE	VERSION	SUMMARY OF CHANGE/MILESTONE
5/24/2010	NA	HAUGEN AND SCHOENDORF determined questions to be included in the Low-Intensity CATI Pregnancy Screener
5/25/2010	20100525	HASHEMI incorporated questions into desired format
5/26/2010	20100526-bjh	HAUGEN made revisions and provided comments when necessary
5/27/2010	20100526-bjh_jj	INCORPORATE VARIABLE SOURCES
5/27/2010	20100527	IRB TEAM added interview instructions to confirm that consent script was administered; added closing script; inserted skip pattern to CS007
6/2/2010	20100602	Comments from NCS PO
6/2/2010	20100602	INFORMAL SUBMISSION TO OMB
6/3/2010	20100603	INCORPORATE COMMENTS FROM OMB HIGHLIGHT LANGUAGE PERTAINING TO ELIGIBILITY (TO BE CORRECTED)
6/7/2010	20100607	INCORPORATE CHANGES FROM J. PARK
6/7/2010	20100607a	INCORPORATE CHANGES FROM J. SLUTSMAN
		RECONCILE WITH DATA ELEMENTS TABLES
		FORMAL SUBMISSION TO OMB
		INCORPORATE COMMENTS FROM OMB
		SUBMIT TO NICHD IRB
		RECONCILE WITH DATA ELEMENTS TABLES

NOTE: Italics denote anticipated development stages

CATI

INTERVIEWER-COMPLETED QUESTIONS

[COMPLETION OF LOW-INTENSITY CONSENT MUST BE OBTAINED FIRST; ASSUME COMPLETION OF LOW-INTENSITY CATI PREGNANCY SCREENER OR RETURN OF PPG SELF-ADMINISTERED QUESTIONNAIRE]

PS001. (TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

[IF SPEAKING TO AN ADULT ABOUT HER OWN PREGNANCY STATUS: (PS002)

PS002.We are asking women of childbearing age a few questions about pregnancy. Not all women who answer these questions will be able to take part in the National Children’s Study now, but almost every woman who answers these questions will have a chance to take part in some way in the future. We first want to know….

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

YES CP000

NO MC001

REFUSED MC001

DON’T KNOW MC001

PS005. IF NO AND AGE < 50 (MC001)

IF NO AND AGE > 50 …………………………………….(CS007) SET (PPG_FIRST) = 5

IF RECENTLY LOST PREGNANCY (MISCARRIAGE/ABORTION)

(CP001A) SET (PPG_FIRST) = 3

IF RECENTLY GAVE BIRTH ……………………………(CS007) SET (PPG_FIRST) = 4

IF UNABLE TO HAVE CHILDREN (HYSTERECTOMY, TUBAL LIGATION)

……… (CS007) (HYSTER)

PROGRAMMER INSTRUCTION: IF PPG_FIRST=3 THEN GO TO CP001A; ELSE IF NOT PREGNANT AND OVER 49, NOT ELIGIBLE FOR THE STUDY, GO TO CS007.

CURRENT PREGNANCY INFORMATION

CP000. We’ll begin by asking some questions about you, your health, and your health history.

First, I’ll ask about your current pregnancy.

CP001A. [I’m so sorry to hear that you’ve lost your baby. I know this can be a hard time.]

PROGRAMMING NOTE [LOCAL OPTION]:

If Center has pregnancy loss information to disseminate, go to CP001C.

Otherwise go to CS007.

INTERVIEWER INSTRUCTIONS: USE SOCIAL CUES AND PROFESSIONAL JUDGMENT WHEN RESPONDING TO PARTICIPANT.

CP001C. DID RESPONDENT REQUEST ADDITIONAL INFORMATION ON COPING WITH PREGNANCY LOSS?

YES 1 (CS007)

NO 2 (CS007)

CP002. What is your current due date?

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

YYYY MM DD

REFUSED 9—97 (CP004)

DON’T KNOW 9—98 (CP004)

CP003. How did you find out your due date?

FIGURED IT OUT MYSELF 1

HAD AN ULTRASOUND TO FIGURE IT OUT 2

DOCTOR OR OTHER PROVIDER TOLD ME

WITHOUT AN ULTRASOUND 3

REFUSED 9—97

DON’T KNOW 9—98

CP004. What was the first day of your last menstrual period?

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

YYYY MM DD

CODE DAY AS “15” IF RESPONDENT IS UNSURE/UNABLE TO ESTIMATE DAY.

REFUSED 9—97

DON’T KNOW 9—98

CP004a. DID RESPONDENT GIVE DATE?

RESPONDENT GAVE COMPLETE DATE 1

INTERVIEWER ENTERED 15 FOR DAY 2

CP005. Did you use a home pregnancy test to help find out you were pregnant?

YES 1

NO 2

REFUSED 9—97

DON’T KNOW 9—98

CP008. Where do you plan to deliver your baby:

In a hospital, 1

A birthing center, 2

At home, or 3 (CP010)

Some other place? 4

REFUSED 9—97 (CP010)

DON’T KNOW 9—98 (CP010)

CP009. What is the name and address of the place where you are planning to deliver your baby?

_____________________________________________________

NAME OF BIRTH HOSPITAL/BIRTHING CENTER

_____________________________________________________

STREET ADDRESS

_____________________________________________________

CITY

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

STATE ZIP CODE

REFUSED 9—97

DON’T KNOW 9—98

CP010. In the month before you became pregnant, did you regularly take multivitamins,

prenatal vitamins, or folic acid?

YES 1

NO 2

REFUSED 9—97

DON’T KNOW 9—98

CP012. Since you’ve become pregnant, have you regularly taken multivitamins, prenatal vitamins, or folic acid?

YES 1

NO 2

REFUSED 9—97

DON’T KNOW 9—98

DV003. What was the date of your most recent doctor’s visit or checkup since you’ve become pregnant?

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

YYYY MM DD

HAVE NOT HAD A VISIT 6 DV013

REFUSED 9—97 DV013

DON’T KNOW 9—98 DV013

DV013. At this visit or at any time during your pregnancy, 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 or low blood count? 1 2 9--97 9--98

g. Severe nausea or vomiting (hyperemesis)? 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. Infection with a bacteria called Group B strep? 1 2 9--97 9--98

k. Infection with a Herpes virus? 1 2 9--97 9--98

l. Infection of the vagina with bacteria (Bacterial vaginosis?) 1 2 9--97 9--98

o. Any other serious condition? (CONDITION_OTH) 1 2 9--97 9—98

INTERVIEWER INSTRUCTIONS: IF DV013a in (1, 2, 9-97, 9-98), THEN GO TO MC005

INTERVIEWER INSTRUCTIONS: IF DV013b in (1, 2, 9-97, 9-98), THEN GO TO MC004

DV014. (CONDITION_OTH)

SPECIFY _____________________________

REFUSED

DON’T KNOW

MEDICAL HISTORY

MC001. This next question is about your health when you are not pregnant.

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

MC103. How tall are you without shoes?

|___| |___|___|

Feet Inches

REFUSED 9—97

DON’T KNOW 9—98

MC104. What was your weight just before you became pregnant?

|___|___|___|

Pounds

REFUSED 9—97

DON’T KNOW 9—98

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

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

YES 1 (MC006)/(THYROID_1)

NO 2 (MC006)/(THYROID_1)

REFUSED 9—97 (MC006)/(THYROID_1)

DON’T KNOW 9—98 (MC006)/(THYROID_1)

MC004. (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 (DV013c)

NO 2 (DV013c)

REFUSED 9—97 (DV013c)

DON’T KNOW 9—98 (DV013c)

MC005. (Have you ever been told by a doctor or other health care provider that you had) High blood sugar or Diabetes when you’re not pregnant?

YES 1

NO 2

REFUSED 9—97

DON’T KNOW 9—98

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

YES 1

NO 2

REFUSED 9—97

DON’T KNOW 9—98

MC005b. Have you ever taken insulin?

YES 1 (DV013b)

NO 2 (DV013b)

REFUSED 9—97 (DV013b)

DON’T KNOW 9—98 (DV013b)

MC006. (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 (MC012a)

REFUSED 9—97 (MC012a)

DON’T KNOW 9—98 (MC012a)

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

YES 1

NO 2

REFUSED 9—97

DON’T KNOW 9—98

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

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

Clinic or health center 1

Doctor's office or Health Maintenance Organization

(HMO) 2

Hospital emergency room 3

Hospital outpatient department 4

Some other place 5

DOESN'T GO TO ONE PLACE MOST OFTEN 6

DOESN'T GET PREVENTIVE CARE ANYWHERE 7

REFUSED 9—97

DON'T KNOW 9—98

HEALTH INSURANCE

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

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

YES 1

NO 2 (HC004)

REFUSED 9—97 (HC004)

DON’T KNOW 9—98 (HC004)

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

currently have.

(Do you currently have:)

YES NO RF DK

a. Insurance through an employer or union either through yourself or

another family member? 1 2 9—97 9—98

b. Medicaid or any government-assistance plan for those with low incomes

or a disability? 1 2 9—97 9—98

c. TRICARE, VA, or other military health care? 1 2 9—97 9—98

d. Indian Health Service? 1 2 9—97 9—98

e. Medicare, for people with certain disabilities? 1 2 9—97 9—98

f. Any other type of health insurance or health coverage plan? 1 2 9—97 9--98

INTERVIEWER INSTRUCTIONS: PROVIDE EXAMPLES OF LOCAL MEDICAID PROGRAMS.

Housing Characteristics

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

2001 TO PRESENT 1

1981 TO 2000 2

1961 TO 1980 3

1941 TO 1960 4

1940 OR BEFORE 5

REFUSED 9—97

DON’T KNOW 9—98

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

ELECTRIC 1

GAS – PROPANE OR LP 2

OIL 3

WOOD 4

KEROSENE OR DIESEL 5

COAL OR COKE 6

SOLAR ENERGY 7

HEAT PUMP 8

NO HEATING SOURCE 9 (HC012)

OTHER (MAIN_HEATING_FUEL_OTH) -5

REFUSED 9—97 (HC012)

DON’T KNOW 9—98 (HC012)

HC007A. (MAIN_HEATING_FUEL_OTH)

SPECIFY _____________________________

REFUSED

DON’T KNOW

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

SELECT ALL THAT APPLY.

Window or wall air conditioners, 1

Central air conditioning, 2

Evaporative cooler (swamp cooler), or 3

NO COOLING OR AIR CONDITIONING REGULARLY

USED 4

Some other cooling system (COOLING_OTH) -5

REFUSED 9—97

DON’T KNOW 9—98

HC012A. (COOLING_OTH)

SPECIFY _____________________________

REFUSED 9—97

DON’T KNOW 9—98

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? (H2O_DRINK_SOURCE_OTH) -5

REFUSED 9—97

DON’T KNOW 9—98

HC034A. (H20_DRINK_SOURCE_OTH)

SPECIFY _____________________________

REFUSED 9—97

DON’T KNOW 9—98

Tobacco and alcohol Use

DA011. Currently, do you smoke cigarettes?

Yes 1

No 2 (DA027)

REFUSED 9--97 (DA027)

DON’T KNOW 9--98 (DA027)

DA012. Do you smoke cigarettes:

Every day 1

5 or 6 days a week 2

2-4 days a week 3

Once a week 4

1-3 days a month 5

Less than once a month 6

REFUSED 9—97

DON’T KNOW 9—98

DA013. On days that you smoke, how many cigarettes do you smoke per day?

|___|___|

NUMBER PER DAY

INTERVIEWER INSTRUCTIONS:

• IF RESPONDENT ANSWERS 1 OR LESS PER DAY, ENTER “1.”

• IF RESPONDENT ANSWERS IN PACKS, CALCULATE AT 20 CIGARETTES PER PACK.

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 (EV001)

REFUSED 9--97 (EV001)

DON’T KNOW 9--98 (EV001)

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

INTERVIEWER INSTRUCTIONS: IF DA029 IN (2,3,4), THEN CONSULT GUIDANCE ON LOCAL MANDATORY REPORTING PROCEDURES.

Evaluation Questions

EV000. We would now like to take a few minutes to ask some questions about your experience in the study.

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

	Not at all Important	Somewhat Important	Very Important
a. Learning more about my health or the health of my child?	_____	_____	_____
b. Feeling as if I can help children now and in the future?	_____	_____	_____
c. Receiving money or gifts for taking part in the study?	_____	_____	____
d. Helping doctors and researchers learn more about children and their health?	_____	_____	_____
e. Helping researchers learn how the environment may affect children’s health?	_____	_____	_____
f. Feeling part of my community?	_____	_____	_____
g. Knowing other women in the study?	_____	_____	_____
h. Having family members or friends support my choice to take part in the study?	_____	_____	_____
i. Having my doctor or health care provider support my choice to take part in the study?	_____	_____	_____

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

	Very Negative	Somewhat Negative	Neither Positive or Negative	Somewhat Positive	Very Positive	NA
a. Your spouse or partner
b. Your other family members	_____	_____	_____	_____	_____	___
c. Your friends	_____	_____	_____	_____	_____	___
d. Your doctor or health care provider	_____	_____	_____	_____	_____	_ ___

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

• Mostly negative

• Somewhat negative

• Neither negative or positive

• Somewhat positive

• Mostly positive

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

• Not at all

• A little

• Some

• A lot

EV008. Did you think the interview was

• Too short

• Too long

• Just about right?

EV009. Do you think the interview was

• Not at all stressful

• A little stressful

• Somewhat stressful

• Very stressful?

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

• Yes

• No

• Refused

• Don’t know

CONCLUSION

CO001. Thank you for participating in the National Children’s Study and for taking the time to answer our questions. If there are any other women in your household age [LOCAL AGE OF MAJORITY] - 49, (please have her | she may) contact us <Study Center Phone Number>. We will contact you in about 6 months to ask you some more questions.

CS007. Thank you for taking the time to answer these questions. Based on what you’ve told me, you are not eligible to take part in the study.

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