Form 8 Survey

OMB #: 0925-0593

Expiration Date: xx/xxxx

JULY LAUNCH VERSION

VERSION 6/7/2010

Recruitment Strategy Substudy

Birth Visit Questionnaire

TABLE OF CONTENTS

CAPI

INTERVIEW INTRODUCTION

Baby Characteristics

HOUSING CHARACTERISTICS

ENVIRONMENTAL EXPOSURES

INFANT FEEDING

INFANT SLEEP

WELL BABY CARE AND IMMUNIZATIONS

WORK AND PLANS FOR CHILDCARE

TRACING QUESTIONS

INTERVIEWER-COMPLETED QUESTIONS

DOCUMENT HISTORY

DATE	VERSION	SUMMARY OF CHANGE/MILESTONE
5/14/2010	20100514	Brenner updated original draft.
5/14/2010	20100514a	J. Park formatted for OMB review
	20100514a	INFORMAL SUBMISSION TO OMB
5/24/2010	20100524	P. Hashemi added OMB code
5/26/2010	20100526	P. Hashemi altered specify items to fit OMB format
5/27/2010	20100527	P. Hashemi formatted variable codes based on Pre-Pregnancy Interview already formatted by J. Graber
5/27/2010	20100527_jj	J. Jay added variable sources
5/27/2010	20100528	IRB team revised interview introductory text
6/2/2010	20100604	NCS PO Group Comments
6/7/2010	20100607	J. Park and J. Slutsman provided edits to instrument

NOTE: Italics denote anticipated development stages

INTERVIEW INTRODUCTION

VS001.Thank you for agreeing to participate in the National Children’s Study. This interview will take about 20 minutes. Your answers are important to us. There are no right or wrong answers. We will ask you about yourself, your baby’s birth, and your plans once you return home. You can skip over any question or stop the interview at any time. We will keep everything that you tell us confidential.

VS002. INTERVIEWER INSTRUCTION: IF ADDITIONAL INFORMATION IS NEEDED, SAY [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.]

VS003. 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.

VS003A. INTERVIEWER INSTRUCTION: IF TWIN OR HIGHER ORDER BIRTH, LOOP BC001 – BC007.

VS004. (TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Baby Characteristics

BC001/ (BABY_NAME) During this interview, we would like to refer to your baby by name. What name would you like me to use to talk about your baby?

NAME PROVIDED 1

INITIALS PROVIDED 2

NO OFFICIAL NAME SELECTED 3

REFUSED -1

DON’T KNOW -2

BC001A. [IF TWIN OR HIGHER ORDER BIRTH] Let’s start with your first [twin/triplet/higher order birth]. What name would you like me to use to talk about your baby?

NAME PROVIDED 1

INITIALS PROVIDED 2

NO OFFICIAL NAME SELECTED 3

REFUSED -1

DON’T KNOW -2

BC002. INTERVIEWER INSTRUCTION: ENTER TEXT AND CONFIRM SPELLING

_____________________

FIRST NAME

(BABY_FNAME)

_____________

MIDDLE NAME

(BABY_MNAME)

___________________

LAST NAME

(BABY_LNAME)

BC007/(BABY_SEX) INTERVIEWER ADMINISTERED QUESTION: WHAT IS THE SEX OF THE BABY?

BOY 1

GIRL 2

BC008/(LIVE_MOM) When [BABY’S NAME] leaves the hospital will [he/she] live with you?

YES 1 (RECENT_MOVE)

NO 2

REFUSED -1

DON’T KNOW -2

BC009. (LIVE_OTH) With whom will [he/she] live?

BABY’S FATHER 01

BABY’S GRANDPARENT(S) 02

OTHER FAMILY MEMBER 03

PLACING IN FOSTER CARE 04

PLACING FOR ADOPTION 05

REFUSED -1

DON’T KNOW -2

BC010/(TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HOUSING CHARACTERISTICS

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

YES 1

NO 2(RENOVATE)

REFUSED -1(RENOVATE)

DON’T KNOW -2(RENOVATE)

HC004/(OWN_HOME) Is your current home…

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

Rented by you or someone in your household, or 2

SOME OTHER ARRANGEMENT (OWN_HOME_OTH) -5

REFUSED -1

DON’T KNOW -2

HC005. (OWN_HOME_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

HC006/(AGE_HOME) Can you tell us when your home or building was built? Was it between…

2001 to present, 1

1981 to 2000, 2

1961 to 1980, 3

1941 to 1960, or 4

1940 or before 5

REFUSED -1

DON’T KNOW -2

HC007/(LENGTH_RESIDE)/(LENGTH_RESIDE_UNIT) How long have you lived in this home?

|___|___|

NUMBER

WEEKS 1

MONTHS 2

YEARS 3

REFUSED -1

DON’T KNOW -2

HC009/INTERVIEWER INSTRUCTION: ENTER IN NUMERIC VALUE AND SELECT ASSOCIATED UNIT OF TIME

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF VALUE > 18 YEARS

HC010/(TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

ENVIRONMENTAL EXPOSURES

EE001/(RENOVATE) The next few questions ask about any recent additions or renovations to your home.

Since our last contact, have any additions been built onto your home to make it bigger or renovations or other construction been done in your home? Include only major projects. Do not count smaller projects such as painting or wallpapering, carpeting, or refinishing floors..

YES 1

NO 2 / (DECORATE)

REFUSED -1 / (DECORATE)

DON’T KNOW -2 / (DECORATE)

EE002/(RENOVATE_ROOM) Which rooms were renovated?

INTERVIEWER INSTRUCTION: SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

RESPONDENT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER (RENOVATE_ROOM_OTH) - 5

REFUSED -1

DON’T KNOW -2

EE003. (RENOVATE_ROOM_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

EE004/(DECORATE) Since our last contact, were any smaller projects done in your home, such as painting, wallpapering, refinishing floors, or installing new carpet?

YES 1

NO 2 /(SMOKE)

REFUSED - 1 /(SMOKE)

DON’T KNOW -2/ (SMOKE)

EE005/(DECORATE_ROOM) In which rooms were these smaller projects done?

INTERVIEWER INSTRUCTION: SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

RESPONDENT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER (DECORATE_ROOM_OTH) - 5

REFUSED -1

DON’T KNOW -2

EE006. (DECORATE_ROOM_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

EE007/(SMOKE) Currently, do you or others in your household smoke cigarettes, cigarillos, cigars, pipes or other tobacco products?

YES 1

NO 2 / (HOSPITAL)

REFUSED -1 / (HOSPITAL)

DON’T KNOW -2 / (HOSPITAL)

EE008/(SMOKE_LOCATE) Do those who smoke usually smoke indoors, outdoors, or both indoors and outdoors?

INDOORS 1

OUTDOORS 2

BOTH 3

REFUSED -1

DON’T KNOW -2

EE009. (TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

INFANT FEEDING

IF001/(FED_BABY) Have you fed [BABY’S NAME] since [his/her] birth?

YES 1

NO 2/ (PLAN_FEED)

REFUSED -1

DON’T KNOW -2

IF002/(HOW_FED) Did you breast or bottle feed?

BREAST 1

BOTTLE 2

BOTH BREAST AND BOTTLE 3

REFUSED -1

DON’T KNOW -2

IF003/(PLAN_FEED) After you leave the hospital do you plan to feed the baby breast milk, formula or both?

BREAST MILK 1

FORMULA 2

BOTH BREAST MILK AND FORMULA 3

REFUSED -1

DON’T KNOW -2

IF004/(TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

INFANT SLEEP

IS001/(POS_HOSP) Do the nurses here in the hospital usually put [BABY’S NAME] to sleep on [his/her] stomach, back, or side?

STOMACH 1

BACK 2

SIDE 3

REFUSED -1

DON’T KNOW -2

IS002/(POS_HOME) In what position do you plan to put [BABY’S NAME] to sleep at home?

STOMACH 1

BACK 2

SIDE 3

REFUSED -1

DON’T KNOW -2

IS003/(SLEEP_ROOM) When you go home from the hospital do you plan for [BABY’S NAME] to sleep…

In [his/her] own room, 1

In a room with other children, 2

In your bedroom, or 3

Another location? 4

REFUSED -1

DON’T KNOW -2

IS004/(BED) When you go home from the hospital do you plan for [BABY’S NAME] to sleep in …

A bassinette, 1

A crib, 2

A co-sleeper, 3

An adult bed alone, 4

An adult bed with you, 5

An adult bed with another child, or 6

Something else (BED_OTH) -5

REFUSED -1

DON’T KNOW -2

IS005. (BED_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

IS006/(TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

WELL BABY CARE AND IMMUNIZATIONS

WB001/ (HCARE) Where do you plan to take your new baby for well-baby checkups?

Hospital clinic 1

Health department clinic 2

Private doctor’s office or HMO 3

Other (HCARE_OTH) -5

REFUSED -1

DON’T KNOW -2

WB002/ (HCARE_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

WB003/ (VACCINE) Do you plan for your new baby to have well-baby shots or vaccinations?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

WB004/ (TIME_STAMP_8) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

WORK AND PLANS FOR CHILDCARE

CC001/(EMPLOY2) Are you currently employed?

YES 1

NO 2 / (CHILDCARE)

REFUSED -1

DON’T KNOW -2

CC002/(RETURN_JOB) When do you plan to return to your current job?

|___|___|

NUMBER

DAYS 0

WEEKS 1

MONTHS 2

YEARS 3

DOESN’T PLAN TO RETURN TO WORK 4

REFUSED -1

DON’T KNOW -2

CC003. INTERVIEWER INSTRUCTION: ENTER IN NUMERIC VALUE AND SELECT ASSOCIATED UNIT OF TIME

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF VALUE > 1 YEAR

CC004/ (CHILDCARE) Next I would like to ask you a few questions about your plans for childcare.

Do you plan for (BABY’S NAME) to receive regularly scheduled care from someone other than you or the baby’s father?

YES 1

NO 2 / (TIME_STAMP_9)

REFUSED -1

DON’T KNOW -2

CC005/(CCARE_TYPE) Please describe the type of setting in which most of the childcare will occur.

PARTICIPANTS HOME 1

OTHER PRIVATE HOME 2

CHILD CARE CENTER 3

OTHER (CCARE_TYPE_OTH) -5

REFUSED -1

DON’T KNOW -2

CC006. (CCARE_TYPE_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

CC007/ (CCARE_WHO) Which best describes the person who will be caring for [BABY’S NAME]?

YOUR MOTHER 1

YOUR FATHER 2

YOUR MOTHER IN-LAW 3

YOUR FATHER IN-LAW 4

GUARDIAN 5

OTHER RELATIVE (REL_CARE_OTH) 6

FRIEND 7

NANNY 8

PROFESSIONAL IN HOME DAYCARE 9

PROFESSIONAL CENTER BASED DAYCARE 10

OTHER (CCARE_WHO_OTH) - 5

REFUSED -1

DON’T KNOW -2

CC008. (REL_CARE_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

CC009. (CCARE_WHO_OTH)

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

CC010/ (TIME_STAMP_9) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TRACING QUESTIONS

TR001. These next few questions will help us to contact you again in the future.

TR002/ (R_FNAME)/(R_LNAME) What is your full name?

INTERVIEWER INSTRUCTION: CONFIRM SPELLING OF FIRST NAME IF NOT PREVIOUSLY COLLECTED AND OF LAST NAME FOR ALL RESPONDENTS.

_____________________ ___________________

FIRST NAME LAST NAME

REFUSED -1

DON’T KNOW -2

TR003/ (PHONE_NBR) What is the best phone number to reach you?

INTERVIEWER INSTRUCTION: ENTER PHONE NUMBER AND CONFIRM.

|___|___|___| - |___|___|___| - |___|___|___|___|

RESPONDENT HAS NO TELEPHONE 1 / (TR004)

REFUSED -1/ (HOME_PHONE)

DON’T KNOW -2/ (HOME_PHONE)

TR004/ INTERVIEWER INSTRUCTION: IF RESPONDENT DOES NOT HAVE A TELEPHONE NUMBER, ASK WHERE RESPONDENT RECEIVES TELEPHONE CALLS, EVEN IF THEY DO NOT HAVE THEIR OWN PHONE. ASK FOR AND RECORD THAT NUMBER.

TR005/(PHONE_TYPE) Is that your home, work, cell, or another phone number?

INTERVIEWER INSTRUCTION: CONFIRM IF KNOWN.

HOME 1/ (SAME_ADDR)

WORK 2

CELL 3

FRIEND/RELATIVE 4/ (FRIEND_PHONE_OTH)

OTHER 5/ (PHONE_TYPE_OTH)

REFUSED -1

DON’T KNOW -2

TR006. (FRIEND_PHONE_OTH)

SPECIFY

REFUSED -1

DON’T KNOW -2

TR007. (PHONE_TYPE_OTH)

SPECIFY

REFUSED -1

DON’T KNOW -2

TR008/(HOME_PHONE) What is your home phone number?

INTERVIEWER INSTRUCTION: ENTER PHONE NUMBER AND CONFIRM.

|___|___|___| - |___|___|___| - |___|___|___|___|

NO HOME NUMBER

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: IF TR005 = 3 THEN SKIP TR00X AND GO TO TR106.

TR00X/(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

PROGRAMMER INSTRUCTION: IF TR005 = 3 SKIP TR109.

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

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

PHONE NUMBER

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: IF HC001 = 1 THEN GO TO HC002 ELSE GO TO TR009.

HC002/(MOVE_INFO) What is the address of your [new] home?

ADDRESS KNOWN 1

OUT OF THE COUNTRY 2

PO BOX ADDRESS ONLY 3

REFUSED -1

DON’T KNOW -2

HC003/(NEW ADDRESS VARIABLES) INTERVIEWER INSTRUCTION: 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 -1

DON’T KNOW -2

TR009/(SAME_ADDR) Is your mailing address the same as your street address?

YES 1/ (HAVE_EMAIL)

NO 2

REFUSED -1

DON’T KNOW -2

TR010/ (MAILING ADDRESS VARIABLES) What is your mailing address?

INTERVIEWER INSTRUCTION: 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 -1

DON’T KNOW -2

TR011/(HAVE_EMAIL) Do you have an email address?

YES 1

NO 2/ (PLAN_MOVE)

REFUSED -1 /( PLAN_MOVE)

DON’T KNOW - 2 (PLAN_MOVE)

TR012/(EMAIL) What is the best email address to reach you?

ENTER E-MAIL ADDRESS: ___________________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: SHOW EXAMPLE OF VALID EMAIL ADDRES SUCH AS [email protected]

TR013/(EMAIL_TYPE) Is that your personal e-mail, work e-mail, or a family or shared e-mail address?

PERSONAL 1

WORK 2

FAMILY/SHARED 3/ (EMAIL_SHARE)

REFUSED -1

DON’T KNOW -2

TR014/(EMAIL_SHARE) PROGRAMMER INSTRUCTION: CODE AS SHARED EMAIL ADDRESS.

TR015/(PLAN_MOVE) Do you plan on moving from your present address in the next few months?

YES 1/ (WHERE_MOVE)

NO (END OF INTERVIEW)

REFUSED (END OF INTERVIEW)

DON’T KNOW (END OF INTERVIEW)

TR016/ (WHERE_MOVE) Do you know where you will be moving?

YES 1/ (MOVE_INFO)

NO 2/ (WHEN_MOVE)

REFUSED -1 (WHEN_MOVE)

DON’T KNOW -2 (WHEN_MOVE)

TR017/(MOVE_INFO) What is the address of your new home?

ADDRESS KNOWN 1/ (NEW ADDRESS VARIABLES)

OUT OF THE COUNTRY 2/ (WHEN_MOVE)

PO BOX ADDRESS ONLY 3/ (WHEN_MOVE)

REFUSED -1/ (WHEN_MOVE)

DON’T KNOW -2/ (WHEN_MOVE)

TR018/(NEW ADDRESS VARIABLES) ENTER ADDRESS

INTERVIEWER INSTRUCTION: 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 -1

DON’T KNOW -2

TR019/ (WHEN_MOVE) Do you know when you will be moving?

YES 1/ (DATE_MOVE)

NO 2

REFUSED -1

DON’T KNOW -2

TR020/(DATE_MOVE) When will you move?

MONTH: |___|___|

M M

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: FORMAT DATE_MOVE AS YYYYMM

TR021/(TIME_STAMP_10) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TR022/(END_OF_INTERVIEW) Thank you for participating in the National Children’s Study and for taking the time to answer our questions.

INTERVIEWER-COMPLETED QUESTIONS

IC001. (TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IC002/ (RESPONDENT) WAS THE INTERVIEW COMPLETED WITH THE BIRTH MOTHER OR A PROXY?

BIRTH MOTHER 01

PROXY 02

IC003/ (CONTACT_TYPE) IN WHAT MODE WAS THE QUESTIONNAIRE ADMINISTERED?

IN-PERSON 1

TELEPHONE 2

MAIL 3

WEB 4

IC004/(ENGLISH) WAS THIS DATA COLLECTION SESSION CONDUCTED IN ENGLISH?

YES 1/ (TIME_STAMP_12)

NO 2/ (CONTACT_LANG)

IC005/ (CONTACT_LANG) WHAT OTHER LANGUAGE WAS USED TO CONDUCT THIS SESSION?

SPANISH 01

ARABIC 02

CHINESE 03

FRENCH 04

FRENCH CREOLE 05

GERMAN 06

ITALIAN 07

KOREAN 08

POLISH 09

RUSSIAN 10

TAGALOG 11

VIETNAMESE 12

URDU 13

PUNJABI 14

BENGALI 15

FARSI 16

OTHER (CONTACT_LANG_OTH) -5

IC006. (CONTACT_LANG_OTH)

SPECIFY ________________________

IC007/(INTERPRET) WAS AN INTERPRETER USED?

YES 1/ (CONTACT_INTERPRET)

NO 2/ (TIME_STAMP_12)

IC008/(CONTACT_INTERPRET) WHAT TYPE OF INTERPRETER WAS USED?

BILINGUAL INTERVIEWER 01

IN-PERSON PROFESSIONAL INTERPRETER 02

IN-PERSON FAMILY MEMBER INTERPRETER 03

LANGUAGE-LINE INTERPRETER 04

VIDEO INTERPRETER 05

OTHER (CONTACT_INTERPRET_OTH) - 5

IC009. (CONTACT_ INTERPRET_OTH)

SPECIFY ________________________

IC010. (TIME_STAMP_12) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.