Form 1 Survey

OMB #: 0925-0593

Expiration Date: xx/xxxx

JULY LAUNCH VERSION

VERSION 6/7/2010

Recruitment Strategy Substudy

Household Enumeration Script

TABLE OF CONTENTS

CAPI

VERBAL CONSENT TO SCREENING FOR STUDY ELIGIBILITY

General Eligibility Questions

Household Roster

Summary of Women in Housheold

Hidden Dwelling Units

TRACING QUESTIONS

Summary of Eligibility Status

Interviewer-Completed Questions

NOTE: Questionnaire and other required text is shown in regular font. Interviewer instructions and text not to be read to respondents is shown in ALL CAPS. Introductory text that may or may not be appropriate for all recruitment strategies is shaded. Variable names are shown in BOLD CAPS.

DOCUMENT HISTORY

DATE	VERSION	SUMMARY OF CHANGE/MILESTONE
….	20100430	GRABER INITIAL DRAFT, J. PARK INITIAL FORMATTING FOR LINEAR REVIEW
5/6/2010 AM	20100430	DISCUSSED WITH OMB
5/6/2010 PM	20100430_JG EDITS	COMMENTS FROM CC
5/9/2010	20100509	J. PARK/GRABER ADJUDICATION; APPLY NEW INSTRUMENT FORMAT TO SECTION AD FOR COMMENT
5/10/2010	20100510	REMOVE REFERENCE TO CATI; RESTORE TO WORKING INSTRUMENT FORMAT FOR INTERNAL CONSISTENCY
		POST ON PORTAL FOR NCS PO/NCS COMMENTS
5/23/2010	20100521	INCORPORATE OMB COMMENTS AND NCS COMMENTS, RECONCILE WITH INSTRUMENT FORMAT OF 05/07/10
5/26/2010	20100521_jj	INCORPORATE SOURCES
5/27/2010	20100527	INCORPORATE EDITS FROM IRB TEAM
5/28/2010	20100527	RECONCILE / ACCEPT CHANGES
6/1/2010	20100527	GRABER REVIEW
6/2/2010	20100602	COMMENTS FROM GRABER, BRENNER, SCHOENDORF, J. PARK, HAUGEN, HIRSCHFELD, SLUTSMAN CHANGE ELIGIBILITY AND ROUTING TO AGE OF MAJORITY TO AGE 49, NO EMANCIPATED MINORS [TO BE CORRECTED – HIGHLIGHTED HERE]
6/7/2010	20100607	INCORPORATE COMMENTS FROM J. PARK
6/7/2010	20100607a	INCORPORATE COMMENTS FROM J. SLUTSMAN
		SUBMIT TO OMB (FORMAL)
		SUBMIT TO NCS IRB
		RECONCILE WITH DATA ELEMENTS TABLE

NOTE: Italics denote anticipated development stages.

CAPI

VERBAL CONSENT TO SCREENING FOR STUDY ELIGIBILITY

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

INTERVIEWER INSTRUCTION: IF SOMEONE WHO APPEARS TO BE UNDER 18 YEARS OLD ANSWERS THE DOOR, ASK TO SPEAK WITH AN ADULT BEFORE PROCEEDING WITH THE INTRODUCTION.

AD001. Hello, I’m [INTERVIEWER NAME] from [LOCAL STUDY AFFILIATE]. [SHOW ID BADGE.]

We’re conducting an important research study called the National Children’s Study with the National Institutes of Health. You may have gotten a letter and brochure from us about it [HAND LETTER AND BROCHURE TO R]. The purpose of the study is to improve the health and well-being of children.

AD002. I only need a few minutes of your time. Even if there are no children living at this address, it’s important to see if anyone in your household may be eligible to take part in the study. Can we ask you some questions to see if anyone in the household may be eligible to take part in the Study? You can skip over any question I ask and we can stop at any time. The information we collect from you is protected by law and we will keep all of it private.

INTERVIEWER INSTRUCTION: IF 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 to take part in this study.

AD003. (HH_MEMBER) Are you a member of this household (and at least [LOCAL AGE OF MAJORITY])?

YES

NO  ASK TO SPEAK WITH AN ADULT HOUSEHOLD MEMBER AND RE-READ INTRODUCTION

OPTION 1- IF NO ONE HOME OF LOCAL AGE OF MAJORITY OR OLDER , INTERVIEWER INSTRUCTION: Thank you for your time. When would be the best time to reach someone who lives here who is [LOCAL AGE OF MAJORITY] or older?

LEAVE COPY OF STUDY BROCHURE AND RECORD CONTACT INFORMATION CASE MANAGEMENT SYSTEM

OPTION 2- NO ONE HOME [LOCAL AGE OF MAJORITY] OR OLDER LIVES IN THE DWELLING UNIT INTERVIEWER INSTRUCTION: LEAVE STUDY BROCHURE AND RECORD CONTACT INFORMATION IN CASE MANAGEMENT SYSTEM

REFUSED  LEAVE STUDY BROCHURE AND RECORD CONTACT INFORMATION IN CASE MANAGEMENT SYSTEM

DON’T KNOW  LEAVE STUDY BROCHURE AND RECORD CONTACT INFORMATION IN CASE MANAGEMENT SYSTEM

General Eligibility Questions

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

GE001. First, I’d like to make sure I have the correct address. Just to confirm, what is the address of this household?

PROGRAMMER INSTRUCTION: DISPLAY ADDRESS AS KNOWN; ALLOW INTERVIEWER TO MAKE CORRECTIONS

INTERVIEWER INSTRUCTION: CONFIRM ADDRESS IF R PREVIOUSLY STATED IT.

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)

REFUSED

DON’T KNOW

INTERVIEWER INSTRUCTION: THIS QUESTION REFERS TO THE RESPONDENT’S HOME ADDRESS AND IS USED TO CONFIRM ELIGIBILITY. INTERVIEWERS MUST CHECK RESPONDENT’S ADDRESS AGAINST LISTING OF ELIGIBLE ADDRESSES. IF ADDRESS IS NOT ON LIST, CASE SHOULD BE DISPOSITIONED AS INELIGIBLE.

• IF THE RESPONDENT DOES NOT LIVE AT THIS ADDRESS, CHECK ELIGIBLE ADDRESS LISTING AND SELECT CORRECT ADDRESS. IF ADDRESS IS NOT AN ELIGIBLE DWELLING UNIT, DO NOT COMPLETE THE REST OF THE QUESTIONNAIRE AND END THE INTERVIEW. THANK RESPONDENT FOR HIS/HER TIME.

• IF THE RESPONDENT REFUSES TO ANSWER THE ADDRESS QUESTION, DESCRIBE HOW HIS/HER ELIGIBILITY IS DETERMINED BY HIS/HER RESIDENTIAL ADDRESS AND THAT ALL DATA ARE KEPT CONFIDENTIAL AND SECURE. IF RESPONDENT STILL REFUSES, END THE INTERVIEW AND CODE AS A REFUSAL AND COMPLETE A NON-INTERVIEW REPORT.

• IF DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.

GE002. (PRIVATE) Is this a private residence?

INTERVIEWER INSTRUCTIONS: DO NOT CONSIDER GROUP QUARTERS TO BE A PRIVATE RESIDENCE.

YES  GO TO (TIME_STAMP_4)

NO

REFUSED

DON’T KNOW

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

GE003. (PLACE_TYPE) What type of place is this?

SENIOR LIVING  GO TO (TIME_STAMP_11); THEN OPTION 4

MILITARY BARRACKS  GO TO (TIME_STAMP_11); THEN OPTION 4

RELIGIOUS QUARTERS  GO TO (TIME_STAMP_11); THEN OPTION 4

ON-CAMPUS STUDENT HOUSING  GO TO (TIME_STAMP_11); THEN OPTION 4

CORRECTIONAL FACILITY  GO TO (TIME_STAMP_11); THEN OPTION 4

HOMELESS SHELTER

GROUP HOME FOR MENTALLY ILL

JOB CORPS HOUSING

DOMESTIC VIOLENCE SHELTER

HALFWAY HOUSE

PRIVATE RESIDENCE  GO TO (TIME_STAMP_4)

OTHER (PLACE_TYPE_OTH)

REFUSED

DON’T KNOW

GE003A. (PLACE_TYPE_OTH)

SPECIFY _____________________________

REFUSED

DON’T KNOW

GE004. (PLACE_NAME) What is the name of this place?

INTERVIEWER INSTRUCTION: CONFIRM SPELLING.

____________________________________________________________

NAME OF GROUP LIVING QUARTERS

REFUSED

DON’T KNOW

GE005. (ADMIN) Since this building has group living quarters, I will need to talk to a manager or administrator. Is a manager or administrator available to speak with me now?

YES  GO TO GE006 (ROOMS)

NO

REFUSED

DON’T KNOW

INTERVIEWER INSTRUCTION: IF MANAGER OR ADMINISTRATOR IS AVAILABLE REPEAT INTRODUCTION/CONSENT AND CONTINUE TO GE006.

OTHERWISE SAY “ Thank you for your time. When would be a good time to come back to speak with the manager or administrator?” RECORD TIME AND DAYS MANAGER OR ADMINISTRATOR AVAILABLE

PROGRAMMER INSTRUCTIONS: WHEN CASE IS RE-OPENED WITH A MANAGER OR ADMINISTRATOR, BEGIN WITH INTRODUCTION AND CONSENT AND THEN SKIP TO QUESTION GE006 (ROOMS)

GE006. (ROOMS) [SPEAKING TO A BUILDING MANAGER] Are there any rooms at this address set aside for staff that would be considered their permanent residence?

YES

NO

REFUSED

DON’T KNOW

GE007. (RESIDE_AGE) Can female residents [or staff] between the ages of [LOCAL AGE OF MAJORITY] and 49 live here?

PROGRAMMER INSTRUCTIONS: IF GE006 (ROOMS) = YES, THEN FILL QUESTION TEXT WITH “or staff.”

YES  GO TO GE008 (RESIDE_PREG)

NO

REFUSED

DON’T KNOW

PROGRAMMER/INTERVIEWER INSTRUCTION: IF AGE-ELIGIBLE WOMEN ARE NOT ALLOWED TO LIVE IN GROUP QUARTERS  GO TO (TIME_STAMP_11), OPTION 4, AND DISPOSITION THE ADDRESS AS INELIGIBLE

GE008. (RESIDE_PREG) Can pregnant women [including staff] living here have a baby and continue to live here?

PROGRAMMER INSTRUCTIONS: IF (GE006) (ROOMS) = YES, THEN FILL QUESTION TEXT WITH “or staff.”

YES  GO TO (TIME_STAMP_4)

NO

REFUSED

DON’T KNOW

PROGRAMMER/INTERVIEWER INSTRUCTION: IF PREGNANT-ELIGIBLE WOMEN ARE NOT ALLOWED TO LIVE IN GROUP QUARTERS  GO TO (TIME_STAMP_11), OPTION 4, AND DISPOSITION THE ADDRESS AS INELIGIBLE

Household Roster

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

HR001. (R_GENDER) IS RESPONDENT MALE OR FEMALE?

INTERVIEWER INSTRUCTION: SELECT BY OBSERVATION.

MALE

FEMALE

HR002. (NUM_ADULT) (Including yourself,) what is the total number of adults [LOCAL AGE OF MAJORITY] or older who live here?

[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.]

INTERVIEWER INSTRUCTION: IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.

IF DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.

|___|___|

NUMBER OF ADULTS IN HOUSEHOLD

REFUSED  (TIME_STAMP_9)

DON’T KNOW

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF RESPONSE > 10; PROMPT INTERVIEWER TO CONFIRM

INTERVIEWER INSTRUCTION: IF RESPONSE = 0; LEAVE STUDY BROCHURE AND RECORD CONTACT INFORMATION IN CASE MANAGEMENT SYSTEM

HR003. (NUM_MALE) Including yourself, how many men [LOCAL AGE OF MAJORITY] or older live here?

PROGRAMMER INSTRUCTION: IF (R_GENDER) = MALE, INCLUDE TEXT IN PARENTHESES

|___|___|

NUMBER OF ADULT MALES

REFUSED

DON’T KNOW

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF RESPONSE > 10; PROMPT INTERVIEWER TO CONFIRM

HR004. (NUM_FEMALE) (Including yourself, how/How) many women [LOCAL AGE OF MAJORITY] or older live here?

PROGRAMMER INSTRUCTION: IF (HR001) (R_GENDER) = FEMALE, INCLUDE TEXT IN PARENTHESES

|___|___|

NUMBER OF ADULT FEMALES

REFUSED

DON’T KNOW

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF RESPONSE > 10; PROMPT INTERVIEWER TO CONFIRM

PROGRAMMER INSTRUCTIONS: SUM OF (HR003) (NUM_MALE) AND (HR004) (NUM_FEMALE) SHOULD BE EQUAL TO (HR002) (NUM_ADULT)

INTERVIEWER INSTRUCTION: IF EDIT CHECK FAILS, ATTEMPT TO CONFIRM INFORMATION

HR006. (AGE_ELIG)

PROGRAMMER INSTRUCTIONS:

• ASK IF (HR004) (NUM_FEMALE) > 1 OR REFUSED/DON’T KNOW

• IF (HR001) (R_GENDER) = FEMALE INSERT “including yourself”

This study is looking at children’s health, including development before birth. We are interested in women between [LOCAL AGE OF MAJORITY] and 49. Thinking only about women ages [LOCAL AGE OF MAJORITY] to 49 [including yourself], how many women [LOCAL AGE OF MAJORITY] to 49 live here?

INTERVIEWER INSTRUCTION: IF REFUSED, ATTEMPT TO CONVERT. IF FAIL, SELECT REFUSED.

IF DON’T KNOW, ASK TO SPEAK WITH ANOTHER ADULT HH MEMBER WHO KNOWS. IF CANNOT FIND ANOTHER ADULT WHO KNOWS, SELECT DON’T KNOW.

|___|___|

NUMBER OF WOMEN [LOCAL AGE OF MAJORITY] -49

REFUSED

DON’T KNOW

PROGRAMMER INSTRUCTION:

• INCLUDE SOFT EDIT IF HR006 (AGE_ELIG) RESPONSE > 10; PROMPT INTERVIEWER TO CONFIRM

• INCLUDE HARD EDIT IF HR006 (AGE_ELIG) RESPONSE > (HR004) (NUM_FEMALE)

CREATE VARIABLE NUM_AGE_ELIG = TOTAL NUMBER OF WOMEN IN HH AGES [LOCAL AGE OF MAJORITY] -49

(TIME_STAMP_5). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HR005. (PREGNANT) Is anyone living in the household currently pregnant?

YES

NO

REFUSED

DON’T KNOW

HR007. (NUM_PREG) PROGRAMMER INSTRUCTION: ASK IF (PREGNANT) = YES

You mentioned that someone who lives in the household is pregnant. How many women currently living here are pregnant?

|___|___|

NUMBER OF PREGNANT WOMEN

NO ONE IN HOUSEHOLD IS PREGNANT  GO TO (TIME_STAMP_6)

REFUSED

DON’T KNOW

PROGRAMMER INSTRUCTION:

• INCLUDE SOFT EDIT IF (HR007) (NUM_PREG) RESPONSE > 5; PROMPT INTERVIEWER TO CONFIRM

• INCLUDE HARD EDIT IF (HR007) (NUM_PREG)RESPONSE > HR004 (NUM_FEMALE)

HR008. (P_AGE) I have a few more questions about [her/them]. This information will help us to determine whether [she/they] may be able to take part in the National Children’s Study.

Thinking about the [oldest/next] pregnant woman living in the household, how old [is she/are you]? If you are unsure, please make your best guess.

|___|___|

AGE

IF YOUNGER THAN LOCAL AGE OF MAJORITY, GO TO TIME_STAMP_6

NO ONE IN HOUSEHOLD IS PREGNANT  GO TO TIME_STAMP_6

REFUSED

DON’T KNOW

HR009. (P_FNAME) What is [her/your] first name?

INTERVIEWER INSTRUCTION: CONFIRM SPELLING.

____________________________________________________________

FIRST NAME

REFUSED

DON’T KNOW

HR010. (P_RELATE) How is she related to you?

INTERVIEWER INSTRUCTION: IF YOU ARE CERTAIN THE RESPONDENT IS SPEAKING ABOUT HERSELF, SELECT ‘SELF’ AND DO NOT READ THIS QUESTION.

SELF

WIFE

DAUGHTER

GRAND-DAUGHTER

MOTHER

GRAND-MOTHER

SISTER

PARTNER

ROOMMATE

OTHER RELATIVE

OTHER NON-RELATIVE

REFUSED

DON’T KNOW

PROGRAMMER INSTRUCTIONS:

• LOOP THROUGH QUESTIONS HR008 (P_AGE), HR009 (P_FNAME), HR010 (P_RELATE) FOR THE TOTAL NUMBER OF WOMEN IDENTIFIED IN HR007 (NUM_PREG)

• AFTER ALL LOOPS ARE COMPLETED

• CREATE VARIABLE TO CAPTURE THE TOTAL NUMBER OF PREGNANT WOMEN IN HOUSEHOLD WHERE NUM_PREG = TOTAL NUMBER OF PREGNANT WOMEN.

• CREATE VARIABLE TO COUNT THE PREGNANT WOMEN IN HOUSEHOLD STRATIFIED BY AGE WHERE

  • NUM_PREG_ADULT = NUMBER OF PREGNANT WOMEN AT LOCAL AGE OF MAJORITY OR OLDER

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

PROGRAMMER INSTRUCTIONS: USING THE RESPONSE TO NUM_AGE_ELIG AND THE CALCULATED NUM_PREG_ADULT VALUE, SUBTRACT NUM_PREG_ADULT FROM NUM_AGE_ELIG TO DETERMINE THE NUMBER OF TIMES QUESTIONS HR011 (AGE_ELIG_FNAME), HR012 (AGE_ELIG_AGE), HR013 (AGE_ELIG_RELATE)

MUST BE ASKED. LOOP THROUGH THESE QUESTIONS UNTIL COMPLETE.

HR011. (AGE_ELIG_FNAME) Please think about the other women in your household who are between ages [LOCAL AGE OF MAJORITY] and 49 and who we haven’t already talked about. Let’s start with the oldest.

What is [her/your] first name?

INTERVIEWER INSTRUCTION: CONFIRM SPELLING.

____________________________________________________________

FIRST NAME

REFUSED

DON’T KNOW

HR012. (AGE_ELIG_AGE) How old [is she/are you]?

|___|___|

AGE

OUTSIDE OF ELIGIBLE AGE RANGE (LOCAL AGE OF MAJORITY -49)

REFUSED

DON’T KNOW

PROGRAMMER INSTRUCTIONS: IF AGE < LOCAL AGE OF MAJORITY OR >49 DISPLAY ERROR MESSAGE

INTERVIEWER INSTRUCTIONS: CONFIRM CORRECT AGE AND ENTER.

HR013. (AGE_ELIG_RELATE) How is she related to you?

INTERVIEWER INSTRUCTION: IF YOU ARE CERTAIN THE RESPONDENT IS SPEAKING ABOUT HERSELF, SELECT ‘SELF’ AND DO NOT READ THIS QUESTION.

SELF

WIFE

DAUGHTER

GRAND-DAUGHTER

MOTHER

GRAND-MOTHER

SISTER

PARTNER

ROOMMATE

OTHER RELATIVE

OTHER NON-RELATIVE

REFUSED

DON’T KNOW

Summary of Women in HousEHOld

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

PROGRAMMER INSTRUCTIONS: UPDATE VARIABLES

• NUM_PREG = TOTAL NUMBER OF PREGNANT WOMEN.

• NUM_PREG_ADULT = NUMBER OF PREGNANT WOMEN [LOCAL AGE OF MAJORITY] OR OLDER

• NUM_AGE_ELIG = TOTAL NUMBER OF WOMEN IN HH AGES [LOCAL AGE OF MAJORITY] -49

DISPLAY THE NAMES, AGES, AND PREGNANCY STATUS OF EACH WOMEN IDENTIFIED. TOTAL NUMBER OF NCS ELIGIBLE WOMEN SHOULD BE FILLED INTO TEXT BELOW (ALL PREGNANT + AGE-ELIGIBLE).

WO001. Thank you. I have recorded that there are [NUMBER] women in the household who may be able to participate in the Study.

INTERVIEWER INSTRUCTION: READ NAMES AND CONFIRM LISTING WITH RESPONDENT

WO002. (CONFIRM_1) This number should include all women who are age [LOCAL AGE OF MAJORITY] to 49, or are currently pregnant, who usually live here, even those who may be temporarily away, such as on business, on vacation, on active military duty, in a hospital or in school. Is this correct?

YES, ALL INFORMATION IS CORRECT

NO, THERE ARE ERRORS IN THE LISTING  GO TO WO003 (CONFIRM_2)

REFUSED

DON’T KNOW

PROGRAMMER INSTRUCTION:

• ALLOW INTERVIEWER TO EDIT EACH RECORD TO CORRECT THE NAME, AGE, PREGNANCY STATUS, AND RELATIONSHIP FOR EACH IDENTIFIED WOMAN

• ALLOW INTERVIEWER TO DELETE RECORDS ENTERED IN ERROR

• ALLOW INTERVIEWER TO ADD RECORDS MISSED ORIGIANLLY

• WHEN COMPLETE, DISPLAY CORRECTED LISTING AND CONFIRM IN WO003 BELOW.

INTERVIEWER INSTRUCTION: READ NAMES AND CONFIRM WITH RESPONDENT AGAIN

WO003. (CONFIRM_2) Is this [ADJUSTED NUMBER] correct?

YES, ALL INFORMATION IS CORRECT

NO, THERE ARE ERRORS IN THE LISTING

REFUSED

DON’T KNOW

PROGRAMMER INSTRUCTION: MAKE FURTHER CORRECTIONS UNTIL COMPLETE AND ACCURATE, THEN  GO TO (TIME_STAMP_8).

PROGRAMMER INSTRUCTIONS: UPDATE VARIABLES

• NUM_PREG = TOTAL NUMBER OF PREGNANT WOMEN.

• NUM_PREG_ADULT = NUMBER OF PREGNANT WOMEN [LOCAL AGE OF MAJORITY] OR OLDER

• NUM_AGE_ELIG = TOTAL NUMBER OF WOMEN IN HH AGES [LOCAL AGE OF MAJORITY] -49

Hidden Dwelling Units

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

PROGRAMMER INSTRUCTION: ASK SECTION ONLY IF (PRIVATE = YES) OR (PLACE_TYPE = PRIVATE RESIDENCE); ELSE GO TO (TIME_STAMP_9)

HD001. (RESIDENCE_TYPE). IS THIS BUILDING A…

SINGLE-FAMILY HOME

MULTI UNIT/APARTMENT  GO HD004 /(ENUM_STATUS)

GROUP QUARTERS  GO TO (TIME_STAMP_9)

INTERVIEWER INSTRUCTION: DO NOT READ QUESTION TO RESPONDENT; SELECT BY OBSERVATION. IF UNSURE SELECT SINGLE-FAMILY HOME.

HD002. (APT_1). I want to be sure that every household in this area has been given a chance to participate in this important study. Are there any other living quarters here such as an attic or basement apartment?

YES  GO TO HD003/(APT_2)

NO  GO TO (TIME_STAMP_9)

REFUSED  GO TO (TIME_STAMP_9)

DON’T KNOW  GO TO (TIME_STAMP_9)

HD003. (APT_2) Where is this unit located?

INTERVIEWER INSTRUCTION: FOLLOW HIDDEN DU PROCEDURE. IF NEEDED, RECORD UNIT ADDRESS OR LOCATION/ DESCRIPTION.

LOCATION COLLECTED

REFUSED

DON’T KNOW

HD004. (ENUM_STATUS) [INTERVIEWER ANSWERED]: IS THIS THE FIRST UNIT ENUMERATED IN THE BUILDING?

YES (COME BACK TO HIDDEN DU PROCEDURE)

NO (HIDDEN DU PROCEDURE NOT REQUIRED)

Tracing QUESTIONS

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

TR001. I have a few more questions for you. All of your information is kept completely confidential. Would you please tell me your name?

INTERVIEWER INSTRUCTION: CONFIRM FIRST NAME IF KNOWN. IF RESPONDENT IS UNWILLING TO PROVIDE INFORMATION, ASK FOR INITIALS

_________________________ (R_FNAME)

FIRST NAME

_________________________ (R_LNAME)

LAST NAME

REFUSED

DON’T KNOW

TR002. (R_PHONE) And what is the best phone number to reach you?

INTERVIEWER INSTRUCTION: IF RESPONDENT SAYS THEY HAVE NO TELEPHONE, ASK AT WHAT NUMBER THEY RECEIVE TELEPHONE CALLS

|__|__|__| |__|__|__| -- |__|__|__|__|

PHONE NUMBER

RESPONDENT HAS NO TELEPHONE NUMBER  GO TO (TIME_STAMP_11)

REFUSED  GO TO (TIME_STAMP_11)

DON’T KNOW  GO TO (TIME_STAMP_11)

TR003. (R_PHONE_TYPE) Is this your home, work, cell, or another phone number?

HOME

WORK

CELL

FRIEND/RELATIVE (SPECIFY):

OTHER(R_PHONE_TYPE_OTH)

REFUSED

DON’T KNOW

TR003A. (R_PHONE_TYPE_OTH)

SPECIFY _____________________________

REFUSED

DON’T KNOW

TR109. What is your personal cell phone number?

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

PHONE NUMBER

NONE 9—91

REFUSED 9—97

DON’T KNOW 9—98

tr120. (R_PHONE_ALT) Is there an alternate phone number to reach you?

|__|__|__| |__|__|__| -- |__|__|__|__|

PHONE NUMBER

RESPONDENT HAS NO TELEPHONE NUMBER  GO TO (TIME_STAMP_11)

REFUSED  GO TO (TIME_STAMP_11)

DON’T KNOW  GO TO (TIME_STAMP_11)

TR121. (R_PHONE_ALT_TYPE) Is this your home, work, cell, or another phone number?

HOME

WORK

CELL

FRIEND/RELATIVE (SPECIFY): __________________________

OTHER(R_PHONE_ALT_TYPE_OTH)

REFUSED

DON’T KNOW

TR121A. (R_PHONE_ALT_TYPE_OTH):

SPECIFY _____________________________

REFUSED

DON’T KNOW

Summary of Eligibility Status

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

PROGRAMMER INSTRUCTION: DISPLAY FINAL LISTING OF ALL WOMEN ELIGIBLE TO BE ADMINISTERED THE PREGNANCY SCREENER.

INTERVIEWER INSTRUCTION: BASED ON FINAL LISTING, USE THE FOLLOWING CLOSING STATEMENTS AND DISPOSITION CASE AS APPROPRIATE.

(HH_ELIG)

ES001. ELIGIBILITY CLOSING STATEMENT AND DISPOSITION CASE OPTIONS

(HH_ELIG = 1)

OPTION 1: HOUSEHOLD INFORMANT IS ELIGIBLE FOR PREGNANCY SCREENER

ES001A. It looks like you may be able to take part in this Study. To find out, I need to ask you a few more questions. This should only take about 20 minutes.

INTERVIEWER INSTRUCTION: BEGIN ADMINISTRATION OF PREGNANCY SCREENER

(HH_ELIG = 2)

OPTION 2: ONE OR MORE WOMEN IN HOUSEHOLD ARE ELIGIBLE FOR PREGNANCY SCREENER

ES001B. It looks like some women in this household may be able to take part in this Study. May I speak to... [NAMES OF AGE-ELIGIBLE IDENTIFIED WOMEN]?

INTERVIEWER INSTRUCTION: ATTEMPT TO COMPLETE PREGNANCY SCREENER OR SET APPOINTMENTS WITH IDENTIFIED WOMEN (OR LEGAL GUARDIAN, AS REQUIRED).

(HH_ELIG = 3)

OPTION 3: NO CURRENT HOUSEHOLD MEMBERS ARE ELIGIBLE FOR PREGNANCY SCREENER

ES001C. Right now, there is no one here that can take part in the study. 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 your time.

(HH_ELIG = 4)

OPTION 4: DWELLING UNIT IS NOT ELIGIBLE

ES001D. Thank you for your time. There is no one here that can take part in the study.

Interviewer-Completed Questions

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

IN001. (CONTACT_TYPE) IN WHAT MODE WAS THE QUESTIONNAIRE ADMINISTERED?

IN-PERSON

TELEPHONE

MAIL

WEB

IN002. (ENGLISH) WAS THIS DATA COLLECTION SESSION CONDUCTED IN ENGLISH?

YES

NO  GO TO IN003/ (CONTACT_LANG)

IN003. (CONTACT_LANG) WHAT OTHER LANGUAGE WAS USED TO CONDUCT THIS SESSION?

SPANISH

ARABIC

CHINESE

FRENCH

FRENCH CREOLE

GERMAN

ITALIAN

KOREAN

POLISH

RUSSIAN

TAGALOG

VIETNAMESE

URDU

PUNJABI

BENGALI

FARSI

OTHER (CONTACT_LANG_OTH)

IN003A. (CONTACT_LANG_OTH):

SPECIFY _____________________________

REFUSED

DON’T KNOW

IN004. (INTERPRET) WAS AN INTERPRETER USED?

YES  GO TO IN005

NO  GO TO TIME_STAMP_13

IN005. (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)

IN005A. (CONTACT_INTERPRET_OTH):

SPECIFY _____________________________

REFUSED

DON’T KNOW

(TIME_STAMP_13). PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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