Form 2 Survey
Recruitment Strategy Substudy for the National Children's Study (NICHD)
Pregnancy Screener July Launch 20100607a
Two Tier (High): Pregnancy Screening
OMB: 0925-0593
Recruitment Strategy Substudy
Pregnancy Screener
TABLE OF CONTENTS
CAPI or CATI
VERBAL CONSENT TO SCREENING FOR STUDY ELIGIBILITY
ELIGIBILITY QUESTIONS
FAMILIARITY WITH THE NATIONAL CHILDREN’S STUDY
PREGNANCY SCREENER
DEMOGRAPHIC QUESTIONS
TRACING QUESTIONS
CLOSING STATEMENTS
FINAL INTERVIEWER-COMPLETED QUESTIONS
NOTE: Questionnaire and other required text is shown in regular font. Interviewer instructions and text not to be read to participants is shown in ALL CAPS. Introductory text that may or may not be appropriate for all recruitment schemas is shaded. Variable names are shown in BOLD CAPS.
DOCUMENT HISTORY
DATE |
VERSION |
SUMMARY OF CHANGE/MILESTONE |
5/7/2010 |
20100510 |
GRABER AND J. PARK ADJUDICATION MARSTAT VAR CONSISTENT WITH VAR USED IN ORIGINAL VANGUARD STUDY; EMPLOYMENT VAR RETAINED AND PROPOSED FOR UPDATE TO PREGNANCY INTERVIEWS FOR INTERNAL CONSISTENCY |
5/12/2010 |
20100512 |
Correction to dk/ref categories in Final Interviewer-Completed Questions (GRABER) |
5/24/2010 |
20100524 |
Reconcile with other documents for format and sourcing |
5/25/2010 |
20100525 |
COMMENTS FROM SLUTSMAN/IRB TEAM |
5/26/2010 |
20100526 |
GRABER AND J. PARK ADJUDICATION OF COMMENT FROM SLUTSMAN/IRB TEAM |
5/27/2010 |
20100527 |
INCORPORATE EDITS FROM IRB TEAM |
5/28/2010 |
20100527 |
RECONCILE COMMENTS |
6/1/2010 |
20100527 |
Graber comments |
6/2/2010 |
20100602 |
COMMENTS FROM GRABER, BRENNER, SLUTSMAN, J. PARK, SCHOENDORF, HIRSCHFELD
|
6/7/2010 |
20100607 |
INCORPORATE COMMENTS FROM J. PARK |
6/7/2010 |
20100607a |
INCORPORATE EDITS FROM J. SLUTSMAN |
|
|
INFORMAL SUBMISSION TO OMB |
|
|
INCORPORATE COMMENTS FROM OMB |
|
|
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
CAPI or cati
VERBAL CONSENT TO SCREENING FOR STUDY ELIGIBILITY
IC001. TO BE READ TO ELIGIBLE FEMALES WHO WERE NOT ALREADY CONSENTED AS PART OF A HOUSEHOLD ENUMERATION OR SOME OTHER STUDY ELEMENT.
IC002. Hello, I’m [DATA COLLECTOR’S NAME] from [LOCAL STUDY AFFILIATE].
INTERVIEWER INSTRUCTION: SHOW ID BADGE.
IC003. IF LOCATING Previously Identified ELIGIBLE Female for ScreeniNG:
THEN (IC004)
else (IC007)
IC004. IF ELIGIBLE FEMALE IS AN ADULT (AT LEAST THE AGE OF MAJORITY): (IC005)
IC005. Is [ELIGIBLE FEMALE’S NAME] available?
IC007. We’re conducting an important research study called the National Children’s Study with the [NAME OF LOCAL ACADEMIC INSTITUTION]. You may have gotten a letter and brochure from us about it.
IC008. INTERVIEWER INSTRUCTION: HAND LETTER AND BROCHURE TO RESPONDENT.
The purpose of the study is to improve the health and well being of children.
IC009. INTERVIEWER INSTRUCTION: IF ADDITIONAL INFORMATION IS NEEDED, SAY:
As the letter says, the information we get from those who take part in the study may help us learn information that will improve our children’s health for years to come. Your household is in one of the areas that have been chosen for the study.
IC010. IF ELIGIBLE FEMALE IS AN ADULT (AT LEAST THE AGE OF MAJORITY): (IC011)
IC011. We are speaking with women ages [LOCAL AGE OF MAJORITY] to 49.
IC013. I only need a few minutes of your time. Can I ask you some questions to determine if you might be eligible to participate in the Study? You can skip over any question I ask or you can stop the interview at any time. The Information we collect from you is protected by law and we will keep all of it private.
IF ADDITIONAL INFORMATION IS NEEDED, SAY
IC014. You may be receiving government benefits, such as Social Security or Medicaid.
Nothing will happen to those benefits if you decide to take part or not take part in this
study.
IC015. INTERVIEWER INSTRUCTION: CONTINUE UNLESS RESPONDENT ASKS QUESTIONS OR REFUSES TO PARTICIPATE. IF RESPONDENT REFUSES, DISPOSITION CONTACT AS A REFUSAL AND COMPLETE A NON-INTERVIEW REPORT.
ELIGIBILITY QUESTIONS
EL001. INTERVIEWER INSTRUCTION: THESE QUESTIONS ARE TO BE ADMINISTERED TO AN ADULT, AT LOCAL AGE OF MAJORITY OR OLDER.
EL002. (TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP
EL003. (PERSON_DOB) I’ll begin by asking some general questions. What is yourdate of birth?
MONTH: |___|___|
M M
DAY: |___|___|
D D
YEAR: |___|___|___|___|
Y Y Y Y
REFUSED (EL004) (AGE) DON’T KNOW (EL004) (AGE)
PROGRAMMER INSTRUCTION:
INCLUDE A SOFT EDIT/WARNING IF CALCULATED AGE IS LESS THAN LOCAL AGE OF MAJORITY OR GREATER THAN 50
FORMAT PERSON_DOB AS YYYYMMDD
CALCULATE AGE AND AGE_RANGE BASED ON RESPONSE; SKIP TO (EL007)
IF ONLY MONTH AND YEAR ARE PROVIDED, CALCULATE AGE AND SKIP TO (EL007)
EL004. (AGE) How old {are you/is [NAME]}?
ENTER AGE AT LAST BIRTHDAY IN YEARS
|___|___| (EL007)
AGE
REFUSED (EL005) (AGE_RANGE)
DON’T KNOW (EL005) (AGE_RANGE)
PROGRAMMER INSTRUCTION: INCLUDE A SOFT EDIT/WARNING IF AGE ENTERED IS LESS THAN LOCAL AGE OF MAJORITY OR GREATER THAN 50; CALCULATE AGE_RANGE BASED ON RESPONSE
EL005. (AGE_RANGE) INTERVIEWER INSTRUCTION: DESCRIBE HOW THE ANSWER TO THIS QUESTION DETERMINES HER ELIGIBILITY AND THAT ALL DATA ARE KEPT CONFIDENTIALAND SECURE.
Which range best describes your age? Would you say…
Less than 18 (EL007) (PS_STATUS_1)
18-24 (EL007) (PS_STATUS_1)
25-34 (EL007) (PS_STATUS_1)
35-44 (EL007) (PS_STATUS_1)
45-49 (EL007) (PS_STATUS_1)
50-64 (EL007) (PS_STATUS_1)
65 or older (EL007) (PS_STATUS_1)
REFUSED (EL006)
DON’T KNOW (EL006)
EL006. {RESPONDENT REFUSES TO ANSWER}: DESCRIBE HOW HER ELIGIBILITY IS
DETERMINED AND THAT ALL DATA ARE KEPT CONFIDENTIAL AND SECURE.
INTERVIEWER INSTRUCTIONS: IF RESPONDENT STILL REFUSES/DON’T KNOW:
GO TO EL015 (OWN_HOME)
END THE INTERVIEW, THANKING THE RESPONDENT
CODE AS A REFUSAL
COMPLETE A NON-INTERVIEW REPORT
COMPLETE INITIAL INTERVIEWER QUESTIONS STARTING AT (II001) (TIME_STAMP_3)
COMPLETE FINAL INTERVIEWER QUESTIONS STARTING AT (FI001) (TIME_STAMP_11)
EL007. (PS_STATUS_1). INTERVIEWER/PROGRAMMER INSTRUCTION: BASED ON REPORTED AGE OF RESPONDENT DETERMINE WHETHER SHE IS CONSIDERED A MINOR BASED ON LOCAL REQUIREMENTS. IF RESPONDENT IS DETERMINED TO BE A MINOR, GO TO CS007.
R IS AN ADULT (AGE OF MAJORITY OR OLDER) (EL011)
R IS A MINOR: (CS007)
EL010. INTERVIEWER INSTRUCTIONS:
GO TO EL015 (OWN_HOME)
END THE INTERVIEW, THANKING THE RESPONDENT
CODE AS A REFUSAL
COMPLETE A NON-INTERVIEW REPORT
COMPLETE FINAL INTERVIEWER QUESTIONS STARTING AT (FI001) (TIME_STAMP_11)
EL011. (TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP
EL012. (ADDRESS VARIABLES) What is your address?
ADDRESS 1 (ADDRESS_1)
STREET NUMBER
PRE-DIRECTIONAL
STREET NAME
STREET TYPE
POST DIRECTIONAL
ADDRESS 2 (ADDRESS_2)
UNIT (UNIT)
UNIT TYPE
UNIT NUMBER
CITY (CITY)
STATE (STATE)
ZIP CODE (ZIP)
ZIP+4 (ZIP4) (EL014) (DU_ELIG_CONFIRM)
REFUSED (EL013)
DON’T KNOW (EL013)
EL013. {RESPONDENT REFUSES/DON’T KNOW}: DESCRIBE HOW HER ELIGIBILITY IS DETERMINED BY HER RESIDENTIAL ADDRESS AND THAT ALL DATA ARE KEPT CONFIDENTIAL AND SECURE.
INTERVIEWER INSTRUCTIONS: IF RESPONDENT STILL REFUSES/DON’T KNOW:
GO TO EL015 (OWN_HOME)
END THE INTERVIEW, THANKING THE RESPONDENT
CODE AS A REFUSAL
COMPLETE A NON-INTERVIEW REPORT
COMPLETE FINAL INTERVIEWER QUESTIONS STARTING AT (FI001) (TIME_STAMP_11)
EL014. (DU_ELIG_CONFIRM) INTERVIEWER INSTRUCTION: THIS QUESTION IS USED TO CONFIRM ELIGIBILITY.
RESPONDENT LIVES IN AN ELIGIBLE DWELLING UNIT
(EL015) (OWN_HOME)
RESPONDENT DOES NOT LIVE IN AN ELIGIBLE DWELLING UNIT
(CS001) (TIME_STAMP_10)
EL015. (OWN_HOME) Is your home…
Owned or being bought by you or someone in your household………………….(EL016)
Rented by you or someone in your household, or ………………………………..(EL016)
SOME OTHER ARRANGEMENT (OWN_HOME_OTH) (EL016)
REFUSED (II001)
DON’T KNOW (II001)
EL016. (OWN_HOME_OTH)
SPECIFY ___________________________ (II001)
REFUSED (II001)
DON’T KNOW (II001)
FAMILIARITY WITH THE NATIONAL CHILDREN’S STUDY
FA001. (TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP
FA002. (KNOW_NCS) Before today, had you heard about the National Children’s Study?
YES (FA003) (HOW_KNOW_NCS)
NO (PS001) (TIME_STAMP_5)
REFUSED (PS001) (TIME_STAMP_5) DON’T KNOW (PS001) (TIME_STAMP_5)
FA003. (HOW_KNOW_NCS) How did you hear about the National Children’s Study?
SELECT ALL THAT APPLY AND PROBE FOR ANY OTHER MEANS
ADVANCE LETTER MAILED BY NCS
HOUSEHOLD ENUMERATION
CONTINUOUS TRACKING OF DU – NEW MEMBER OF EXISTING HOUSEHOLD
CONTINUOUS TRACKING OF DU – NEW HOUSEHOLD
PRENATAL CARE PROVIDER
OTHER HEALTH CARE PROVIDER
OTHER NCS RESPONDENT
FRIEND
NEIGHBOR
FAMILY MEMBER
CO-WORKER
SELF/RESPONDENT REFERRAL
SCHOOL
WIC OR OTHER SOCIAL AGENCY
RELIGIOUS ORGANIZATION
COMMUNITY PARTNERS/OUTREACH EVENT
MEDIA: PRINT MEDIA
MEDIA: TV
MEDIA: RADIO
SOCIAL NETWORKING MEDIA (E.G., INTERNET, FACEBOOK, MYSPACE, BLOGS, ETC.)
OTHER (HOW_KNOW_NCS_OTH) (FA008)
REFUSED
DON’T KNOW
FA008. (HOW_KNOW_NCS_OTH)
SPECIFY ___________________________
REFUSED
DON’T KNOW
PREGNANCY SCREENER
PS001. (TIME_STAMP_5) 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 (PS006) (ORIG_DUE_DATE)
NO (PS005)
REFUSED PS012 (TIME_STAMP_6)
DON’T KNOW PS012 (TIME_STAMP_6)
PS005. IF NO AND AGE < 50 (PS012) (TIME_STAMP_6)
IF NO AND AGE > 50 (DE001) (TIME_STAMP_7); SET (PPG_FIRST) = 5
IF RECENTLY LOST PREGNANCY (MISCARRIAGE/ABORTION) (DE001) (TIME_STAMP_7); SET (PPG_FIRST) = 3
IF RECENTLY GAVE BIRTH (DE001) (TIME_STAMP_7); SET (PPG_FIRST) = 4
IF UNABLE TO HAVE CHILDREN (HYSTERECTOMY, TUBAL LIGATION)
(PS014) (HYSTER)
PS006. (ORIG_DUE_DATE)] [Congratulations.] When is yourbaby due?
MONTH: |___|___|
M M
DAY: |___|___|
D D
YEAR: |___|___|___|___|
Y Y Y Y
IF VALID RESPONSE PROVIDED (DE001)/(TIME_STAMP_7)
REFUSED
DON’T KNOW
INTERVIEWER INSTRUCTION:
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR
IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE
PROGRAMMER INSTRUCTIONS:
CHECK REPORTED DUE DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:
IF DATE IS MORE THAN 9 MONTHS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 9 MONTHS FROM TODAY. RE-ENTER DATE.”
IF DATE IS MORE THAN 1 MONTH BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT OCCURRED MORE THAN A MONTH BEFORE TODAY. RE-ENTER DATE.”
IF VALID DUE DATE WAS PROVIDED, SET (ORIG_DUE_DATE) = YYYYMMDD AS REPORTED ; GO TO (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 1
IF NO VALID DATE IS GIVEN GO TO PS008 (DATE_PERIOD)
ASK PS008 (DATE_PERIOD) ONLY OF ADULT
PS008. (DATE_PERIOD) What was the first day of your last menstrual period?
MONTH: |___|___|
M M
DAY: |___|___|
D D
YEAR: |___|___|___|___|
Y Y Y Y
IF VALID RESPONSE PROVIDED (DE001)/(TIME_STAMP_7)
REFUSED (PS009) (WEEKS_PREG)
DON’T KNOW (PS009) (WEEKS_PREG)
INTERVIEWER INSTRUCTION:
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR
IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE
PROGRAMMER INSTRUCTIONS:
CHECK REPORTED MENSTRUAL DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:
IF DATE IS MORE THAN 10 MONTHS BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 10 MONTHS BEFORE TODAY. CONFIRM DATE. IF DATE IS CORRECT, ENTER ‘DON’T KNOW’.”
IF DATE IS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT HAS NOT OCCURRED YET. RE-ENTER DATE.”
IF VALID DATE WAS PROVIDED, CALCULATE DUE DATE FROM THE FIRST DATE OF LAST MENSTRUAL PERIOD AND SET (ORIG_DUE_DATE) (YYYYMMDD) = (DATE_PERIOD) + 280 DAYS; GO TO (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 1
IF NO VALID DATE IS GIVEN GO TO PS009 (WEEKS_PREG)
PS009. (WEEKS_PREG) How many weeks pregnant are younow? If
you’re not sure, please make you best guess.
|___|___|
NUMBER OF WEEKS
IF VALID RESPONSE PROVIDED (DE001)/(TIME_STAMP_7)
REFUSED PS010 (MONTH_PREG)
DON’T KNOW PS010 (MONTH_PREG)
INTERVIEWER INSTRUCTION:
IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE
PROGRAMMER INSTRUCTIONS:
REJECT RESPONSES THAT ARE EITHER < 1 WEEK OR GREATER THAN 43 WEEKS
IF VALID RESPONSE WAS PROVIDED, CALCULATE PS006 (ORIG_DUE_DATE) (YYYYMMDD)=TODAY’S DATE + (280 DAYS – WEEKS_PREG *7); GO TO (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 1
IF NO VALID DATE IS CALCULABLE GO TO PS010 (MONTH_PREG)
PS010. (MONTH_PREG) How many months pregnant are you now? If
you’re not sure, please make you best guess.
|___|___|
NUMBER OF MONTHS
IF VALID RESPONSE PROVIDED (DE001)/(TIME_STAMP_7)
REFUSED (PS011) (TRIMESTER)
DON’T KNOW (PS011) (TRIMESTER)
INTERVIEWER INSTRUCTION:
IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE
PROGRAMMER INSTRUCTIONS:
REJECT RESPONSES THAT ARE EITHER < 1 MONTH OR GREATER THAN 12 MONTHS
IF VALID RESPONSE WAS PROVIDED, CALCULATE DUE DATE AS FROM NUMBER OF MONTHS PREGNANT WHERE (ORIG_DUE_DATE) (YYYYMMDD)=TODAY’S DATE + (280 DAYS –((MONTH_PREG*30) -15)); GO TO (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 1
IF NO VALID RESPONSE IS CALCULABLE GO TO PS011 (TRIMESTER)
PS011. (TRIMESTER) Are you currently in your First, Second, or Third trimester?
1ST TRIMESTER (1-3 MONTHS PREGNANT) (DE001)/(TIME_STAMP_7)
2ND TRIMESTER (4-6 MONTHS PREGNANT) (DE001)/(TIME_STAMP_7)
3RD TRIMESTER (7-9 MONTHS PREGNANT) (DE001) /(TIME_STAMP_7)
REFUSED (DE001) /(TIME_STAMP_7)
DON’T KNOW (DE001) /(TIME_STAMP_7)
PROGRAMMER INSTRUCTIONS: CALCULATE DUE DATE AS FROM REPORTED TRIMESTER
1ST TRIMESTER: ORIG_DUE_DATE = TODAY’S DATE + (280 DAYS – 46 DAYS)
2ND TRIMESTER: (ORIG_DUE_DATE) = TODAY’S DATE + (280 DAYS – 140 DAYS)
3RD TRIMESTER: (ORIG_DUE_DATE) = TODAY’S DATE + (280 DAYS – 235 DAYS)
DON’T KNOW/REFUSED: (ORIG_DUE_DATE) = TODAY’S DATE + (280 DAYS – 140 DAYS)
SET (ORIG_DUE_DATE) = YYYYMMDD AS CALCULATED
SET (PPG_FIRST) = 1
PS012. (TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP
PS013. (TRYING) Are you currently trying to become pregnant?
YES (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) =2
NO PS014 (HYSTER)
RECENTLY LOST PREGNANCY (MISCARRIAGE OR ABORTION)
(DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 3
UNABLE TO HAVE CHILDREN (HYSTERECTOMY, TUBAL LIGATION)
(PS014) (HYSTER)
REFUSED PS014 (HYSTER)
DON’T KNOW PS014 (HYSTER)
PS014. (HYSTER) Do any of the following apply to you? Have you had your uterus removed, sometimes called a hysterectomy?
YES (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 5
NO PS015 (OVARIES)
REFUSED PS015 (OVARIES)
DON’T KNOW PS015 (OVARIES)
PS015. (OVARIES) (READ IF NECESSARY: Have you had…) both ovaries removed?
YES (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 5
NO PS016 (TUBES_TIED)
REFUSED PS016 (TUBES_TIED)
DON’T KNOW PS016 (TUBES_TIED)
PS016. (TUBES_TIED) (READ IF NECESSARY: Have you had…) your tubes tied?
YES (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 5
NO PS017 (MENOPAUSE)
REFUSED PS017 (MENOPAUSE)
DON’T KNOW PS017 (MENOPAUSE)
PS017. (MENOPAUSE) (READ IF NECESSARY: Have you…) stopped having your period or gone through menopause?
YES (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 5
NO PS018 (MED_UNABLE)
REFUSED PS018 (MED_UNABLE)
DON’T KNOW PS018 (MED_UNABLE)
PS018. (MED_UNABLE) Is there any other medical reason why you believe you cannot become pregnant?
YES PS019 (MED_UNABLE_OTH)
NO (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 4
REFUSED (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 4
DON’T KNOW (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 4
PS019. (MED_UNABLE_OTH)
SPECIFY _____________________________
(DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 4
REFUSED (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 4
DON’T KNOW (DE001)/(TIME_STAMP_7); SET (PPG_FIRST) = 4
DEMOGRAPHIC QUESTIONS
DE001. (TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP
DE002. (MARISTAT) I’d like to ask about your marital status. Are you:
Married, 01 (EDUC) (DE003)
Not married but living together with a partner 02 (EDUC) (DE003)
Never been married, 03 (EDUC) (DE003)
Divorced, 04 (EDUC) (DE003)
Separated, or 05 (EDUC) (DE003)
Widowed? 06 (EDUC) (DE003)
REFUSED -1 (EDUC) (DE003)
DON’T KNOW -2 (EDUC) (DE003)
INTERVIEWER INSTRUCTION: CODE FOR SALIENT CATEGORY.
DE003. (EDUC) What is the highest degree or level of school you have completed?
LESS THAN A HIGH SCHOOL DIPLOMA OR GED (EMPLOY) (DE004)
HIGH SCHOOL DIPLOMA OR GED (EMPLOY) (DE004)
SOME COLLEGE BUT NO DEGREE (EMPLOY) (DE004)
ASSOCIATE DEGREE (EMPLOY) (DE004)
BACHELOR’S DEGREE (e.g., BA, BS) (EMPLOY) (DE004)
POST GRADUATE DEGREE (e.g., Masters or Doctoral) (EMPLOY) (DE004)
REFUSED (EMPLOY) (DE004)
DON’T KNOW (EMPLOY) (DE004)
DE004. (EMPLOY) Last week were you working full time, part time, going to school, keeping house, or something else?
WORKING FULL TIME (ETHNICITY) (DE005)
WORKING PART TIME (ETHNICITY) (DE005)
WITH A JOB, BUT NOT AT WORK BECAUSE OF TEMPORARY ILLNESS, VACATION, STRIKE (ETHNICITY) (DE005)
UNEMPLOYED/LAID OFF/LOOKING FOR WORK (ETHNICITY) (DE005)
RETIRED (ETHNICITY) (DE005)
IN SCHOOL (ETHNICITY) (DE005)
KEEPING HOUSE (ETHNICITY) (DE005)
OTHER (EMPLOY_OTH) (DE004A)
REFUSED (ETHNICITY) (DE005)
DON’T KNOW (ETHNICITY) (DE005)
NTERVIEWER INSTRUCTION: CODE FOR SALIENT CATEGORY.
DE004A. (EMPLOY_OTH)
SPECIFY _____________________________ (ETHNICITY) (DE005)
REFUSED (ETHNICITY) (DE005)
DON’T KNOW (ETHNICITY) (DE005)
DE005. (ETHNICITY) Do you consider yourself to be Hispanic, or Latina?
YES .(RACE) (DE006)
NO .(RACE) (DE006)
REFUSED .(RACE) (DE006)
DON’T KNOW .(RACE) (DE006)
DE006.(RACE) What race do you consider yourself to be? You may select one or more.
[USE SHOW CARD]
PROBE: Anything else?
SELECT ALL THAT APPLY.
White, PERSON_LANG) (DE007)
Black or African American, PERSON_LANG) (DE007)
American Indian or Alaska Native, PERSON_LANG) (DE007)
Asian, or PERSON_LANG) (DE007)
Native Hawaiian or Other Pacific Islander? PERSON_LANG) (DE007)
REFUSED PERSON_LANG) (DE007)
DON’T KNOW PERSON_LANG) (DE007)
SOME OTHER RACE? (RACE_OTH) (DE006A)
INTERVIEWER INSTRUCTION. CODE “OTHER” ONLY USE IF VOLUNTEERED.
DE006A. (RACE_OTH)
SPECIFY _____________________________ PERSON_LANG) (DE007)
REFUSED PERSON_LANG) (DE007)
DON’T KNOW PERSON_LANG) (DE007)
DE007. (PERSON_LANG) What is the primary language spoken in your
home?
ENGLISH (TIME_STAMP_8)
SPANISH (TIME_STAMP_8)
ARABIC (TIME_STAMP_8)
CHINESE (TIME_STAMP_8)
FRENCH (TIME_STAMP_8)
FRENCH CREOLE (TIME_STAMP_8)
GERMAN (TIME_STAMP_8)
ITALIAN (TIME_STAMP_8)
KOREAN (TIME_STAMP_8)
POLISH (TIME_STAMP_8)
RUSSIAN (TIME_STAMP_8)
TAGALOG (TIME_STAMP_8)
VIETNAMESE (TIME_STAMP_8)
URDU (TIME_STAMP_8)
PUNJABI (TIME_STAMP_8)
BENGALI (TIME_STAMP_8)
FARSI (TIME_STAMP_8)
OTHER (PERSON_LANG_OTH) (DE008)
REFUSED (TIME_STAMP_8)
DON’T KNOW (TIME_STAMP_8)
DE008. (PERSON_LANG_OTH)
SPECIFY _____________________________ (TIME_STAMP_8)
REFUSED (TIME_STAMP_8)
DON’T KNOW (TIME_STAMP_8)
(TIME_STAMP_8) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP
DE009.Now I’m going to ask a few questions about your income. Family income is important in analyzing the data we collect and is often used in scientific studies to compare groups of people who are similar. Please remember that all the information you provide is confidential.
Please think about your total combined family income during 2009 for all members of the family.
DE010. (HH_MEMBERS) How many household members are supported by your total combined family income?
|___|___|
NUMBER
REFUSED (DE011)
DON’T KNOW (DE011)
PROGRAMMER INSTRUCTION: RESPONSE MUST BE > 0; INCLUDE A SOFT EDIT IF RESPONSE IS > 15
DE010. (NUM_CHILD) How many of those people are children? Please include anyone under 18 years or anyone older than 18 years and in high school.
|___|___|
NUMBER
REFUSED -1
DON’T KNOW -2
PROGRAMMER INSTRUCTIONS:
INCLUDE HARD EDIT IF RESPONSE > HH_SIZE
INCLUDE SOFT EDIT IF RESPONSE > 10
DE011. (INCOME) Of these income groups, which category best represents yourtotal combined family income during the last calendar year?
INTERVIEWER INSTRUCTION: SHOW RESPONDENT CATEGORIES ON SHOW CARD
Less than $4,999 (TR001)
$5,000-$9,999 (TR001)
$10,000-$19,999 (TR001)
$20,000-$29,999 (TR001)
$30,000-$39,999 (TR001)
$40,000-$49,999 (TR001)
$50,000-$74,999 (TR001)
$75,000-$99,999 (TR001)
$100,000-$199,000 (TR001)
$200,000 or more (TR001)
REFUSED (TR001)
DON’T KNOW (TR001)
TRACING QUESTIONS
TR001. (TIME_STAMP_9) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP
TR002.These next few questions will help us to contact you again in the future.
TR003. (R_FNAME)/(R_LNAME) What is your full name?
CONFIRM SPELLING OF FIRST NAME IF NOT PREVIOUSLY COLLECTED AND OF LAST NAME FOR ALL RESPONDENTS.
_____________________ ___________________
FIRST NAME LAST NAME
REFUSED (TR004)
DON’T KNOW (TR004)
TR005. (PHONE_NBR) What is the best phone number to reach you?
ENTER PHONE NUMBER AND CONFIRM.
|___|___|___| - |___|___|___| - |___|___|___|___|
RESPONDENT HAS NO TELEPHONE (TR006) (PHONE_NBR_OTH)
REFUSED (TR009) (HOME_PHONE)
DON’T KNOW (TR009) (HOME_PHONE)
TR006. (PHONE_NBR_OTH): IF RESPONDENT DOES NOT HAVE A TELEPHONE NUMBER, ASK WHERE RESPONDENT RECEIVES TELEPHONE CALLS, EVEN IF SHE DOES NOT HAVE HER OWN PHONE. ASK FOR AND RECORD THAT NUMBER
ENTER PHONE NUMBER AND CONFIRM.
|___|___|___| - |___|___|___| - |___|___|___|___|
REFUSED (TR009) (HOME_PHONE)
DON’T KNOW (TR009) (HOME_PHONE)
TR007. (PHONE_TYPE) Is that your home, work, cell, or another phone number?
CONFIRM IF KNOWN.
HOME (TR105) (CELL_PHONE_1)
WORK (TR105) (CELL_PHONE_1)
CELL (TR105) (CELL_PHONE_1)
FRIEND/RELATIVE (TR008) (PHONE_TYPE_OTH)
OTHER (TR008) (PHONE_TYPE_OTH)
REFUSED (TR010) (SAME_ADDR)
DON’T KNOW (TR010) (SAME_ADDR)
TR008. (PHONE_TYPE_OTH)
SPECIFY _____________________________ (TR009) (HOME_PHONE)
REFUSED (TR009) (HOME_PHONE)
DON’T KNOW (TR009) (HOME_PHONE)
PROGRAMMER INSTRUCTION: IF TR007 (PHONE_TYPE) = HOME, THEN SKIP TR009 AND GO TO TR010.
TR009. (HOME_PHONE) What is your home phone number?
ENTER PHONE NUMBER AND CONFIRM.
|___|___|___| - |___|___|___| - |___|___|___|___|
NO HOME NUMBER (TR010) (SAME_ADDR)
REFUSED (TR010) (SAME_ADDR)
DON’T KNOW (TR010) (SAME_ADDR)
TR010. (SAME_ADDR) Is your mailing address the same as your street address?
YES (TR012) (HAVE_EMAIL)
NO (TR011) (MAILING ADDRESS VARIABLES)
REFUSED (TR011) (MAILING ADDRESS VARIABLES)
DON’T KNOW (TR011) (MAILING ADDRESS VARIABLES)
TR011. (MAILING ADDRESS VARIABLES) What is your mailing address?
PROMPT AS NECESSARY TO COMPLETE INFORMATION
_____________________________________________________
(MAIL_ADDRESS1) ADDRESS 1 - STREET/PO BOX
_____________________________________________________
(MAIL_ADDRESS2) ADDRESS 2
_____________________________________________________
(MAIL_UNIT) UNIT
____________________________________________________
(MAIL_CITY) CITY
|___|___| |___|___|___|___|___| |___|___|___|___
STATE ZIP CODE ZIP+4
(MAIL_STATE) (MAIL_ZIP) (MAIL_ZIP4)
REFUSED (TR012) (HAVE_EMAIL)
DON’T KNOW (TR012) (HAVE_EMAIL)
PROGRAMMER INSTRUCTION: IF TR007 (PHONE_TYPE) = CELL, THEN SKIP TR105 AND GO TO TR106.
TR105. (CELL_PHONE_1). Do you have a personal cell phone?
YES 1
NO 2 (TR001)/(CONTACT_1)
REFUSED -1 (TR001)/(CONTACT_1)
DON’T KNOW -2 (TR001)/(CONTACT_1)
TR106. (CELL_PHONE_2). May we use your personal cell phone to make future study appointments or for appointment reminders?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
TR107. (CELL_PHONE_3). Do you send and receive text messages on your personal cell phone?
YES 1
NO 2 (TR001)/(CONTACT_1)
REFUSED -1 (TR001)/(CONTACT_1)
DON’T KNOW -2 (TR001)/(CONTACT_1)
TR108. (CELL_PHONE_4). May we send text messages to make future study appointments or for appointment reminders?
YES 1
NO 2
REFUSED -1
DON’T KNOW -2
TR109. (CELL_PHONE).What is your personal cell phone number?
|___|___|___|___|___|___|___|___|___|___
PHONE NUMBER
REFUSED -1
DON’T KNOW -2
TR012. (HAVE_EMAIL) Do you have an email address?
YES (TR013) (EMAIL)
NO (TR016) (PLAN_MOVE)
REFUSED (TR016) (PLAN_MOVE)
DON’T KNOW (TR016) (PLAN_MOVE)
TR013. (EMAIL) What is the best email address to reach you?
PROGRAMMER INSTRUCTION: SHOW EXAMPLE OF VALID EMAIL ADDRES SUCH AS [email protected]
ENTER E-MAIL ADDRESS: ___________________________________
REFUSED (TR016) (PLAN_MOVE)
DON’T KNOW (TR016) (PLAN_MOVE)
TR014. (EMAIL_TYPE) Is that your personal e-mail, work e-mail, or a family or shared e-mail address?
PERSONAL (TR016) (PLAN_MOVE)
WORK (TR016) (PLAN_MOVE)
FAMILY/SHARED (TR015) (EMAIL_SHARE)
REFUSED (TR016) (PLAN_MOVE)
DON’T KNOW (TR016) (PLAN_MOVE)
TR015. (EMAIL_SHARE)
PROGRAMMER INSTRUCTIONS: IF RESPONDENT REPORTED A SHARED EMAIL ADDRESS IN (EMAIL_TYPE), SET (EMAIL_SHARE) TO “YES,” THEN GO TO (TR016) (PLAN_MOVE)
TR016. (PLAN_MOVE) Do you plan on moving from your present address in the next few months?
YES (TR017) (WHERE_MOVE)
NO (CS001)/(TIME_STAMP_10)
REFUSED (CS001)/ (TIME_STAMP_10)
DON’T KNOW (CS001)/ (TIME_STAMP_10)
TR017. (WHERE_MOVE) Do you know where youwill be moving?
YES TR018 (MOVE_INFO)
NO TR020 (WHEN_MOVE)
REFUSED TR020 (WHEN_MOVE)
DON’T KNOW TR020 (WHEN_MOVE)
TR018. (MOVE_INFO) What is the address of your new home?
ADDRESS KNOWN TR019 (NEW ADDRESS VARIABLES)
OUT OF THE COUNTRY TR020 (WHEN_MOVE)
PO BOX ADDRESS ONLY TR020 (WHEN_MOVE)
REFUSED TR020 (WHEN_MOVE)
DON’T KNOW TR020 (WHEN_MOVE)
TR019. (NEW ADDRESS VARIABLES) ENTER ADDRESS
PROBE AND ENTER AS MUCH INFORMATION AS R KNOWS.
_____________________________________________________
(NEW_ADDRESS1) ADDRESS 1 - STREET/PO BOX
_____________________________________________________
(NEW_ADDRESS2) ADDRESS 2
_____________________________________________________
(NEW_UNIT) UNIT
____________________________________________________
(NEW_CITY) CITY
|___|___| |___|___|___|___|___| |___|___|___|___
STATE ZIP CODE ZIP+4
(NEW_STATE) (NEW_ZIP) (NEW_ZIP4)
REFUSED
DON’T KNOW
TR020. (WHEN_MOVE) Do you know when you will be moving?
YES TR021 (DATE_MOVE)
NO (CS001) / (TIME_STAMP_10)
REFUSED (CS001) / (TIME_STAMP_10)
DON’T KNOW (CS001) / (TIME_STAMP_10)
TR021. (DATE_MOVE) When will you move?
MONTH: |___|___|
M M
YEAR: |___|___|___|___|
Y Y Y Y
PROGRAMMER
INSTRUCTION: FORMAT DATE_MOVE
AS YYYYMM
REFUSED (CS001) / (TIME_STAMP_10)
DON’T KNOW (CS001) / (TIME_STAMP_10)
CLOSING STATEMENTS
CS001. (TIME_STAMP_10) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP
CS002. (PPG_FIRST)
PROGRAMMER
INSTRUCTIONS: DISPLAY APPROPRIATE PPG ASSIGNMENT FOR
RESPONDENT/MINOR
PREGNANT AND ELIGIBLE 1 (CS003)
HIGH PROBABILITY –TRYING TO CONCEIVE 2 (CS004)
HIGH PROBABILITY – RECENT PREGNANCY LOSS 3 (CS005)
OTHER PROBABILITY – NOT PREGNANT AND NOT TRYING 4 (CS006)
UNABLE TO CONCEIVE, AGE-INELIGIBLE 5 (CS007)
INELIGIBLE DWELLING UNIT 6 (CS008)
CS003. Thank you for taking the time to answer these questions. You are able to be part of this important study because of your due date. I would like to tell you more about it and give you all the information you need to decide if you would like to be part of the study.
CS004. Thank you for taking the time to answer these questions. You are able to be part of this important study because you are currently trying to become pregnant. I would like to tell you more about it and give you all the information you need to decide if you would like to be part of the study.
CS005. [I’m so sorry to hear that you’ve lost your baby. I know this can be a hard time.]
Because your address is in the study area, we may be back in touch at a later time to update your household information. Thank you for taking the time to answer these questions.
CS006. Thank you for taking the time to answer these questions. We will contact you again in about three months to ask a few quick questions and update your household information.
CS007. Thank you for taking the time to answer these questions. Based on what you’ve told me, we will not ask you to take part in the study. Because your address is in the study area, we may be back in touch at later time to update your household information.
CS008. Thank you for taking the time to answer these questions. Based on what you’ve told me, we will not ask you to take part in the study. Thank you for your time.
FINAL INTERVIEWER-COMPLETED QUESTIONS
FI001. (TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP
FI002. (ENGLISH) WAS THIS DATA COLLECTION SESSION CONDUCTED IN ENGLISH?
YES (FI005) (INTERPRET)
NO (FI003) (CONTACT_LANG)
FI003. (CONTACT_LANG) WHAT OTHER LANGUAGE WAS USED TO CONDUCT THIS SESSION?
ENGLISH (FI008)
SPANISH (FI005)
ARABIC (FI005)
CHINESE (FI005)
FRENCH (FI005)
FRENCH CREOLE (FI005)
GERMAN (FI005)
ITALIAN (FI005)
KOREAN (FI005)
POLISH (FI005)
RUSSIAN (FI005)
TAGALOG (FI005)
VIETNAMESE (FI005)
URDU (FI005)
PUNJABI (FI005)
BENGALI (FI005)
FARSI (FI005)
OTHER (CONTACT_LANG_OTH) (FI004)
FI004. (CONTACT_LANG_OTH)
SPECIFY _____________________________ (FI005)
REFUSED (FI005)
DON’T KNOW (FI005)
FI005. (INTERPRET) WAS AN INTERPRETER USED?
YES (FI006) (CONTACT_INTERPRET)
NO (FI008)/(TIME_STAMP_12)
FI006. (CONTACT_INTERPRET) WHAT TYPE OF INTERPRETER WAS USED?
BILINGUAL INTERVIEWER
IN-PERSON PROFESSIONAL INTERPRETER
IN-PERSON FAMILY MEMBER INTERPRETER
LANGUAGE-LINE INTERPRETER
VIDEO INTERPRETER
OTHER (CONTACT_INTERPRET_OTH) (FI007)
FI007. (CONTACT_INTERPRET_OTH)
SPECIFY _____________________________ (FI008)
REFUSED (FI008)
DON’T KNOW (FI008)
FI008. (TIME_STAMP_12) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP
| File Type | application/msword |
| Author | graberje |
| Last Modified By | hashemip |
| File Modified | 2010-06-07 |
| File Created | 2010-06-07 |
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