Form 6 Survey

OMB #: 0925-0593

Expiration Date: xx/xxxx

JULY LAUNCH VERSION

VERSION 6/7/2010

ASSUME PRE-PREGNANCY VISIT WAS

ADMINISTERED UNLESS NOTED

Recruitment Strategy Substudy

Pregnancy Visit 1 Interview

TABLE OF CONTENTS

CAPI

INTERVIEW INTRODUCTION

CURRENT PREGNANCY INFORMATION

MEDICAL HISTORY

HEALTH INSURANCE

HOUSING CHARACTERISTICS

PETS

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS

COMMUTING

TRACING QUESTIONS

FAMILY INCOME

SELF-ADMINISTERED QUESTIONNAIRE

PREGNANCY INTENTIONS AND HISTORY

TOBACCO USE AND ALCOHOL

INTERVIEW EVALUATION

DOCUMENT HISTORY

DATE	VERSION	SUMMARY OF CHANGE/MILESTONE
4/1/2010	20100401	INITIAL DRAFT BY SCHOENDORF AND TANEJA
NA	NA	COMMENTS FROM HIRSCHFELD
4/21/2010	20100420	INFORMAL SUBMISSION TO OMB
5/19/2010	20100507_jj	INCORPORATE VARIABLE SOURCES
5/20/2010	20100519.kcs	INCORPORATE COMMENTS FROM SCs
5/21/2010	Compared Document	COMPARED DOCUMENT VERSIONS 20100420 and 20100519.kcs
5/23/2010	20100521	INCORPORATE COMMENTS FROM OMB
5/27/2010	20100527	STANDARDIZATION BY GRABER
5/28/2010	20100528	REVISED INTERVIEW INTRODUCTORY TEXT; ADDED CLOSING SCRIPT; RECOMMENDED “na” RESPONSE CATEGORY IN ITEM EV004; REMOVED RACE/ETHNICITY QUESTIONS (ASKED IN PREGNANCY SCREENER).
6/2/2010	20100607	GROUP REVIEW
		FORMAL SUBMISSION TO OMB
		INCORPORATE COMMENTS FROM OMB
		SUBMIT TO NICHD IRB
		RECONCILE WITH DATA ELEMENTS TABLES

NOTE: Italics denote anticipated development stages

CAPI

INTERVIEW INTRODUCTION

PROGRAMMER INSTRUCTION: IF WOMEN RECEIVED THE PRE-PREGNANCY INTERVIEW, SET PRE_PREG_INT = 1. ELSE, PRE_PREG_INT = 2.

(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IN001. Thank you for agreeing to participate in the National Children’s Study. This interview will take about 30 minutes to complete. Your answers are important to us. There are no right or wrong answers, just those that help us understand your situation. We will ask you questions about yourself, your health and pregnancy, your lifestyle and where you live during this interview. You can skip over any question or stop the interview at any time. We will keep everything that you tell us confidential.

First, we’d like to make sure we have your correct name and birth date.

IN002/(NAME_CONFIRM). Is your name _____[PRELOAD]____________ ?

YES 1 (IN003)/(DOB_CONFIRM)

NO 2 (IN002A/(FULL_NAME).

REFUSED -1 (IN002A)/(FULL_NAME).

DON’T KNOW -2 (IN002A)/(FULL_NAME).

PROGRAMMER INSTRUCTION; PRELOAD RESPONDENT’S NAME IF KNOWN

IN002A/(FULL_NAME). What is your full name?

_________________________

REFUSED -1 (IN003)/(DOB_CONFIRM)

DON’T KNOW -2 (IN003)/(DOB_CONFIRM)

IN003/(DOB_CONFIRM).Is your birth date DD/MM/YYYY?

YES 1 (TIME_STAMP_2)

NO 2 (IN003A)/(PERSON_DOB).

REFUSED -1 (IN003A)/(PERSON_DOB)

DON’T KNOW -2 (IN003A)/(PERSON_DOB).

PROGRAMMER INSTRUCTION;

• PRELOAD RESPONDENT’S DOB IF KNOWN

• IF RESPONSE = YES, SET PERSON_DOB TO KNOWN VALUE

IN003A/(PERSON_DOB).What is your correct birth date?

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

YYYY MM DD

REFUSED -1 (TIME_STAMP_2)

DON’T KNOW -2 (TIME_STAMP_2)

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 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

• IF VALUE IS REFUSED OR DON’T KNOW FLAG CASE FOR SUPERVISOR REVIEW AT SC TO CONFIRM AGE ELIGIBILITY POST-INTERVIEW.

CURRENT PREGNANCY INFORMATION

(TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

CP000. We’ll begin by asking some questions about you, your health, and your health history. First, I’ll ask about your current pregnancy.

CP001/(PREGNANT). The first questions ask about how your pregnancy is progressing. First, are you still pregnant?

YES 1 (CP002)/(DUE_DATE)

NO 2 (CP001A)/(TIME_STAMP_3)

REFUSED -1(TR010)/( END)

DON’T KNOW -2(TR010)/(END)

(TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

CP001A. I’m so sorry for your loss. I know this can be a difficult time.

INTERVIEWER INSTRUCTIONS: USE SOCIAL CUES AND PROFESSIONAL JUDGMENT IN RESPONSE

PROGRAMMER/INTERVIEWER INSTRUCTION:

• if SC has pregnancy loss information to disseminate, go to CP001C/(LOSS_INFO).

• Otherwise go to TR009/(eND_LOSS).

CP001C/(LOSS_INFO_2).INTERVIEWER ANSWERED QUESTION. DID RESPONDENT REQUEST ADDITIONAL INFORMATION ON COPING WITH PREGNANCY LOSS?

YES 1 (TR009)/(eND_LOSS).

NO 2 (TR009)/(eND_LOSS).

CP002/(DUE_DATE). What is your current due date?

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

YYYY MM DD

REFUSED -1 (CP004)/(DATE_PERIOD).

DON’T KNOW -2 (CP004) /(DATE_PERIOD).

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 (DUE_DATE) = YYYYMMDD AS REPORTED ; GO TO (TIME_STAMP_4)

  • IF NO VALID DATE IS GIVEN  GO TO CP004 (DATE_PERIOD)

CP003/(KNOW_DATE). 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 -1

DON’T KNOW -2

CP004/(DATE_PERIOD). 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 -1

DON’T KNOW -2

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 (DUE_DATE) (YYYYMMDD) = (DATE_PERIOD) + 280 DAYS; GO TO (DE001)/(TIME_STAMP_4)

CP004a/(KNEW_DATE). DID RESPONDENT GIVE DATE?

RESPONDENT GAVE COMPLETE DATE 1

INTERVIEWER ENTERED 15 FOR DAY 2

(TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CP006/(PLURALITY). Are you pregnant with a single baby (singleton), twins, or triplets or other multiple births?

SINGLETON 1

TWINS 2

TRIPLETS OR HIGHER 3

REFUSED -1

DON’T KNOW -2

CP008/(BIRTH_PLAN). Where do you plan to deliver your baby:

In a hospital, 1

A birthing center, 2

At home, or 3 (CP010) /(PN_VITAMIN)

Some other place? 4

REFUSED -1 (CP010) /(PN_VITAMIN)

DON’T KNOW -2 (CP010) /(PN_VITAMIN)

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

_____________________________________________________

NAME OF BIRTH HOSPITAL/BIRTHING CENTER (BIRTH_PLACE)

_____________________________________________________

STREET ADDRESS (B_ADDRESS_1)/(B_ADDRESS_2)

_____________________________________________________

CITY (B_CITY)

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

STATE ZIP CODE

(B_STATE) (B_ZIPCODE)

REFUSED -1

DON’T KNOW -2

CP010/(PN_VITAMIN). In the month before you became pregnant, did you regularly take multivitamins, prenatal vitamins, folate, or folic acid?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CP012./(PREG_VITAMIN) Since you’ve become pregnant, have you regularly taken multivitamins, prenatal vitamins, folate, or folic acid?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DV003 (DATE_VISIT). 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

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR

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?

PROGRAMMER INSTRUCTIONS: IF VALID DATE FOR DATE_VISIT IS PROVIDED, FILL TEXT WITH “AT THIS VISIT OR” OTHERWISE BEGIN QUESITON TEXT WITH ‘AT ANY TIME DURING…”

YES NO RF DK

a. Diabetes (DIABETES_1)? 1 2 -1 -2

b. High blood pressure (HIGHBP_PREG)? 1 2 -1 -2

c. Protein in your urine (URINE)? 1 2 -1 -2

d. Preeclampsia or toxemia (PREECLAMP)? 1 2 -1 -2

e. Early or premature labor (EARLY_LABOR)? 1 2 -1 -2

f. Anemia or low blood count? (ANEMIA) 1 2 -1 -2

g. Severe nausea or vomiting (hyperemesis) (NAUSEA)? 1 2 -1 -2

h. Bladder or kidney Infection (KIDNEY) 1 2 -1 -2

i. Rh disease or isoimmunization (RH_DISEASE)? 1 2 -1 -2

j. Infection with a bacteria called Group B strep?(GROUP_B) 1 2 -1 -2

k. Infection with a Herpes virus? (HERPES) 1 2 -1 -2

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

o. Any other serious condition? (CONDITION_OTH) 1 2 -1 -2

DV014. (CONDITION_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: IF DV013a IN (1, 2, -1, -2) THEN GO TO MC005

INTERVIEWER INSTRUCTION: IF DV013b IN (1, 2, -1, -2) THEN GO TO MC004

MEDICAL HISTORY

(TIME_STAMP_5) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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

MC002./(HEALTH). Would you say your health in general is . . .

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

REFUSED -1

DON’T KNOW -2

MC103./(HEIGHT_FT) ./(HT_INCH). How tall are you without shoes?

|___| |___|___|

Feet Inches

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• INCLUDE A SOFT EDIT IF HEIGHT_FT > 7 OR < 4

• IF HEIGHT_FT IS PROVIDED INCLUDE A SOFT EDIT IF HT_INCH > 12

• IF HEIGHT_FT IS NOT PROVIDED INCLUDE A SOFT EDIT IF HT_INCH > 84 OR < 48

MC104./(WEIGHT). What was your weight just before you became pregnant?

|___|___|___|

Pounds

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: INCLUDE A SOFT EDIT IF WEIGHT < 90 OR > 400

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

MC003/(ASTHMA).. 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 -1 (MC006)/(THYROID_1)

DON’T KNOW -2 (MC006)/(THYROID_1)

MC004./(HIGHBP_NOTPREG). (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 -1 (DV013c)

DON’T KNOW -2 (DV013c)

MC005/(DIABETES_NOTPREG).. (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 (MC006)/(DIABETES_3)

REFUSED -1 ( MC006)/(DIABETES_3)

DON’T KNOW -2 ( MC006)/(DIABETES_3)

MC005a/(DIABETES_2).. Have you taken any medicine or received other medical treatment for diabetes in the past 12 months?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC005b/(DIABETES_3)Have you ever taken insulin?

YES 1 (DV013b)

NO 2 (DV013b)

REFUSED -1 (DV013b)

DON’T KNOW -2 (DV013b)

MC006/(THYROID_1).. (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) /(HLTH_CARE)

REFUSED -1 (MC012A) /(HLTH_CARE)

DON’T KNOW -2 (MC012A) /(HLTH_CARE)

MC006a/(THYROID_2).. Have you taken any medicine or received other medical treatment for a thyroid problem in the past 12 months?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_5A) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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

MC012/(HLTH_CARE) . 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 -1

DON'T KNOW -2

HEALTH INSURANCE

(TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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

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

YES 1

NO 2 (TIME_STAMP_7)

REFUSED -1 (TIME_STAMP_7)

DON’T KNOW -2 (TIME_STAMP_7)

HI002/(INSURE_TYPE_1) – (INSURE_TYPE_6).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 -1 -2

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

or a disability? 1 2 -1 -2

c. TRICARE, VA, or other military health care? 1 2 -1 -2

d. Indian Health Service? 1 2 -1 -2

e. Medicare, for people with certain disabilities? 1 2 -1 -2

f. Any other type of health insurance or health coverage plan? 1 2 -1 -2

Housing Characteristics

(TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC000. Now I’d like to find out more about your home and the area in which you live.

PROGRAMMER INSTRUCTIONS: [IF HC002 IS IN PREGNANCY SCREENER OR PRE-PREGANCY VISIT, THEN ASK HC001.]

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

YES 1(HC002)/(OWN_HOME)

NO 2(HC004)/(AGE_HOME)

REFUSED -1(HC004)/(AGE_HOME)

DON’T KNOW -2(HC004)/(AGE_HOME)

PROGRAMMER INSTRUCTIONS: IF RECENT_MOVE IN (2, -1, 2) THEN

[IF PRE_PREG_INT = 1, SKIP TO TIME_STAMP_8. ELSE

IF PRE_PREG_INT = 2, SKIP TO AGE_HOME.]

IF RECENT_MOVE IN (1) THEN GO TO (OWN_HOME).

HC002/(OWN_HOME). 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

SOME OTHER ARRANGEMENT (OWN_HOME_OTH) -5

REFUSED -1

DON’T KNOW -2

HC002A/(OWN_HOME_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC004/(AGE_HOME).. 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 -1

DON’T KNOW -2

HC005./(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

HC006. Now I’m going to ask about how your home is heated and cooled.

HC007/(MAIN_HEAT).. 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 (HC011)/(COOLING)

OTHER (MAIN_HEAT _OTH) -5

REFUSED -1(HC011)/(COOLING)

DON’T KNOW -2(HC011)/(COOLING)

INTERVIEWER INSTRUCTION: SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT.

HC007A/ (MAIN_HEAT _OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC008/(HEAT2). 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?

SELECT ALL THAT APPLY.

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 OTHER HEATING SOURCE 9

OTHER (HEAT2_OTH) -5

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT.

• PROBE FOR ANY OTHER RESPONSES

HC008A. (HEAT2_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC011/(COOLING).. Does your home have any type of cooling or air conditioning besides fans?

YES 1

NO 2 (TIME_STAMP_8)

REFUSED -1 (TIME_STAMP_8) DON’T KNOW -2 (TIME_STAMP_8)

HC012/(COOL) 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 (COOL_OTH) -5

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: PROBE FOR ANY OTHER RESPONSES

HC012A. (COOL_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_8) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC033. Now I’d like to ask about the water in your home.

HC034/(WATER_DRINK).. 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? (WATER_DRINK)_OTH) -5

REFUSED -1

DON’T KNOW -2

HC034A. (WATER_DRINK)_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC035/(WATER_COOK). 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? (WATER_COOK _OTH) -5

REFUSED -1

DON’T KNOW -2

HC035A. (WATER_COOK _OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

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/(WATER) In the past 12 months, have you seen any water damage inside your home?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HC019/(MOLD). 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 (TIME_STAMP_9)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

HC020. /(ROOM_MOLD) 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 (ROOM_MOLD _OTH) -5

REFUSED -1

DON’T KNOW -2

HC020A. (ROOM_MOLD OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_9) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC021. The next few questions ask about any recent additions or renovations to your home.

HC022/(RENOVATE_P). 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, such as painting, wallpapering, carpeting or re-finishing floors.

YES 1

NO 2 (HC025) /(DECORATE_P).

REFUSED -1 (HC025) /(DECORATE_P).

DON’T KNOW -2 (HC025) /(DECORATE_P).

HC024./ (RENOVATE_ROOM) Which rooms were renovated?

PROBE: Any others?

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

HC024A. (RENOVATE_ROOM_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC025/(DECORATE_P). 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 (TIME_STAMP_10)

REFUSED -1 (TIME_STAMP_10)

DON’T KNOW -2 (TIME_STAMP_10)

HC026/(DECORATE_ROOM) . In which rooms were these smaller projects done?

PROBE: Any others?

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

HC026A. (DECORATE_ROOM_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PETS

PP001. Now I’d like to ask about any pets you may have in your home.

PP002/(PETS). Are there any pets that spend any time inside your home?

YES 1

NO 2 (CO001)

REFUSED -1 (CO001)

DON’T KNOW -2 (CO001)

PP003/(PET_TYPE).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 (PET_TYPE_OTH) -5

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: PROBE FOR ANY OTHER RESPONSES

PP003A. (PET_TYPE_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS

(TIME_STAMP_10) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

OH000. Now, I’d like to ask some questions about your schooling and employment.

PROGRAMMER INSTRUCTION: IF PRE_PREG_INT = 1, ADD TEXT,

The next questions may be similar to those asked the last time we spoke, but we are asking them again because sometimes the answers change.

OH00A/(EDUC). What is the highest degree or level of school that you have completed?

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 01

HIGH SCHOOL DIPLOMA OR GED 02

SOME COLLEGE BUT NO DEGREE 03

ASSOCIATE DEGREE 04

BACHELOR’S DEGREE (e.g., BA, BS) 05

POST GRADUATE DEGREE (e.g., Masters or Doctoral) 06

REFUSED -1

DON’T KNOW -2

OH001/(WORKING) Are you currently working at any full or part time jobs?

YES 1

NO 2 (TIME_STAMP_11)

REFUSED -1 (TIME_STAMP_11)

DON’T KNOW -2 (TIME_STAMP_11)

OH002a/(HOURS). . Approximately how many hours each week are you working?

|___|___|___|

NUMBER OF HOURS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: INCLUDE A SOFT EDIT IF RESPONSE > 60

OH002b/(SHIFT_WORK) . Do you work a shift that starts after 2 pm?

YES 1

NO 2

SOMETIMES 3

REFUSED -1

DON’T KNOW -2

CO001. Next, I’ll be asking about commuting and how you travel from place to place.

CO002/(COMMUTE). Think of the longest regular commute that you take, to work, school, or other places. 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.

CAR 1

BUS 2

TRAIN, SUBWAY, RAIL, OR LIGHT RAIL 3

WALK, BIKE (NON-MOTORIZED) 4

OTHER (COMMUTE_OTH) -5 (CO004)/(LOCAL_TRAV)

DOES NOT HAVE A REGULAR COMMUTE 0 (CO004)/(LOCAL_TRAV)

REFUSED -1 (CO004)/(LOCAL_TRAV)

DON’T KNOW -2 (CO004)/(LOCAL_TRAV)

INTERVIEWER INSTRUCTION: PROBE FOR ANY OTHER RESPONSES

CO002A. (COMMUTE_OTH)

SPECIFY _____________________________

REFUSED -1 (CO004)/(LOCAL_TRAV)

DON’T KNOW -2 (CO004)/(LOCAL_TRAV)

CO003/(COMMUTE_TIME) . 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 -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: INCLUDE SOFT EDIT IF RESPONSE > 60

CO004/(LOCAL_TRAV) . 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 (LOCAL_TRAV_OTH) -5

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: PROBE FOR ANY OTHER RESPONSES

CO004A/(LOCAL_TRAV_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

CO005. Next, I’d like to find out about how often you pump gasoline.

CO006/(PUMP_GAS) . 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, 1

4-6 times per week, 2

2-3 times per week, 3

Once a week, 4

One to three times a month, 5

Less than once a month, or 6

Never? 7

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

DE004A. The next questions may be similar to those asked the last time we contacted you, but

we are asking them again because sometimes the answers change.

DE004/(MARISTAT). . I’d like to ask about your marital status. Are you:

Married, 01

Not married but living together with a partner 02

Never been married, 03 (TIME_STAMP_12)

Divorced, 04 (TIME_STAMP_12)

Separated, or 05 (TIME_STAMP_12)

Widowed? 06 (TIME_STAMP_12)

REFUSED -1 (TIME_STAMP_12)

DON’T KNOW -2 (TIME_STAMP_12)

INTERVIEWER INSTRUCTION: CODE FOR SALIENT CATEGORY.

DE005/(SP_EDUC). What is the highest degree or level of school that your spouse or partner has completed?

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 01

HIGH SCHOOL DIPLOMA OR GED 02

SOME COLLEGE BUT NO DEGREE 03

ASSOCIATE DEGREE 04

BACHELOR’S DEGREE (e.g., BA, BS) 05

POST GRADUATE DEGREE (e.g., Masters or Doctoral) 06

REFUSED -1

DON’T KNOW -2

DE006(SP_ETHNICITY) . Does your spouse or partner consider himself (or herself?) to be Hispanic, or Latino?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DE007(SP_RACE) What race does your spouse (or partner) consider himself [or 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

ONLY USE IF VOLUNTEERED. DON’T ASK

SOME OTHER RACE? (SPOUSE_RACE_OTH) -5

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT.

• PROBE FOR ANY OTHER RESPONSES

DE007a/ (SPOUSE_RACE_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_12) 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

DE010A. (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 your 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

(TIME_STAMP_14) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TR000. The next set of questions asks about different ways we might be able to keep in touch with you. Please remember that all the information you provide is confidential and will not be provided to anyone outside the National Children’s Study.

PROGRAMMER INSTRUCTION: IF PRE_PREG_INT = 1 GO TO TR000A. ELSE, GO TO TR101.

TR000A. When we last spoke, we asked questions about communicating with you through your personal email. Have your email address or preferences regarding use of your personal email changed since then?

YES 1 (TR101)/(HAVE_EMAIL).

NO 2 (TR105A)/(CELL_PHONE).

DON’T REMEMBER 3

REFUSED -1

DON’T KNOW -2

TR101/(HAVE_EMAIL). Do you have a personal email address?

YES 1

NO 2 (TR105)/(CELL_PHONE_1).

REFUSED -1 (TR105)/(CELL_PHONE_1).

DON’T KNOW -2 (TR105)/(CELL_PHONE_1).

TR102/(EMAIL_2). May we use your personal email address to make future study appointments or send appointment reminders?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

TR103/(EMAIL_3). May we use your personal email address for questionnaires (like this one) that you can answer over the Internet?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

TR104/(EMAIL). What is your personal email address?

____________________________________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: IF PRE_PREG_INT = 1 GO TO TR105A. ELSE GO TO TR105.

TR105A/(CELL_PHONE). When we last spoke, we asked questions about communicating with you through your personal cell phone number. Have your cell phone number or preferences regarding use of your personal cell phone number changed since then?

YES 1

NO 2 (TR001A).

DON’T REMEMBER 3

REFUSED -1

DON’T KNOW -2

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

(TIME_STAMP_15) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTION: IF PRE_PREG_INT = 1 THEN GO TO TR001A; ELSE GO TO TR001.

TR001A. sometimes if people move or change their telephone number, we have difficulty reaching them. At our last visit, we asked for contact information for two friends or relatives not living with you who would know where you could be reached in case we have trouble contacting you. Has that information changed since our last visit?

YES 1

NO 2 (TR010/END)

DON’T REMEMBER 3

REFUSED -1

DON’T KNOW -2

TR001/(CONTACT_1). 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 (TIME_STAMP_16)

REFUSED -1 (TIME_STAMP_16)

DON’T KNOW -2 (TIME_STAMP_16)

TR002./(F_NAME_1)/(L_NAME_1). What is this person’s name?

______________ __________________

FIRST NAME LAST NAME

REFUSED -1 (TIME_STAMP_16)

DON’T KNOW -2 (TIME_STAMP_16)

INTERVIEWER INSTRUCTION:

• IF RESPONDENT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TR014/(RELATE_1).What is his/her relationship to you?

MOTHER/FATHER 1

BROTHER/SISTER 2

AUNT/UNCLE 3

GRANDPARENT 4

NEIGHBOR 5

FRIEND 6

OTHER (RELATe1 _OTH) -5

REFUSED -1

DON’T KNOW -2

Tr014a./ (RELATe1_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

TR003./(CONTACT_ADDR_1).What is his/her address?

INTERVIEWER INSTRUCTIONS:

PROMPT AS NECESSARY TO COMPLETE INFORMATION

____________________________________________________

STREET (ADDR1_1)/(ADDR_2_1)/(UNIT_1)

____________________________________________________

CITY (CITY_1)

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

STATE ZIP CODE

(STATE_1) (ZIPCODE_1) (ZIP4_1)

REFUSED -1

DON’T KNOW -2

TR004(CONTACT_PHONE_1) What is his/her telephone number?

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

PHONE NUMBER

CONTACT HAS NO TELEPHONE 1

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

TR005/(CONTACT_2) Now I’d like to collect information on a second contact who does not currently live with you. What is this person’s name?

______________ __________________

FIRST NAME LAST NAME

(F_NAME_2) (L_NAME_2)

NO SECOND CONTACT PROVIDED 11 (TR010)/(end)

REFUSED -1 (TR010)/(end)

DON’T KNOW -2 (TR010)/(end)

INTERVIEWER INSTRUCTION:

• IF RESPONDENT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TR006/(RELATE_2)..What is his/her relationship to you?

MOTHER/FATHER 01

BROTHER/SISTER 02

AUNT/UNCLE 03

GRANDPARENT 04

NEIGHBOR 05

FRIEND 06

OTHER (relate_oth) -5

REFUSED -1

DON’T KNOW -2

tr006a/(relate_oth)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

TR007/(CONTACT_ADDR_2)...What is his/her address?

INTERVIEWER INSTRUCTIONS:

PROMPT AS NECESSARY TO COMPLETE INFORMATION

_____________________________________________________

STREET (ADDR1_2)/(ADDR_2_2)/(UNIT_2)

_____________________________________________________

CITY (CITY_2)

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

STATE ZIP CODE

(STATE_2) (ZIPCODE_2) (ZIP4_2)

REFUSED -1

DON’T KNOW -2

TR008/(CONTACT_PHONE_2).. what is his/her telephone number?

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

PHONE NUMBER

CONTACT HAS NO TELEPHONE 1 (TR010)/(end)

REFUSED -1 (TR010) /(end)

DON’T KNOW -2 (TR010) /(end)

INTERVIEWER INSTRUCTION: IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

TR009/(eND_LOSS). Again, I’d like to say how sorry I am for your loss. {We’ll send the information packet you requested as soon as possible.} Please accept our best wishes for a quick recovery. Thank you for your time. END INTERVIEW. DO NOT ADMINISTER SAQs.

TR010/(END). Thank you for participating in the National Children’s Study and for taking the time to complete this survey. This concludes the interview portion of our visit.

[explain SAQS and RETURN process]

(TIME_STAMP_16) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

SELF-ADMINISTERED QUESTIONAIRE

[INTRODUCTION]

(TIME_STAMP_17) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IN001. Thank you for agreeing to participate in this study. This self-administered questionnaire will take about 10 minutes to complete. There are questions about your pregnancy and your lifestyle. We will also ask you about your satisfaction with our visit with you today.

Your answers are important to us. There are no right or wrong answers. You can always refuse to answer any question or group of questions, and your answers will be kept confidential.

[PREGNANCY INTENTIONS and History]

RH002/(PLANNED) . Regarding this pregnancy, were you trying to become pregnant?

Yes 1

No 2 (RH006)/(WANTED)

REFUSED -1 (RH006) /(WANTED)

DON’T KNOW -2 (RH006) /(WANTED)

RH003/(MONTH_TRY) . For about how many months were you trying to become pregnant? If 1 month or less, enter 1.

|___|___|

MONTHS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: INCLUDE SOFT EDIT IF RESPONSE > 24

RH006/(WANTED) . When you became pregnant, did you yourself actually want to have a baby at sometime?

Yes 1

No 2 (TIME_STAMP_18)

REFUSED -1 (TIME_STAMP_18)

DON’T KNOW -2 (TIME_STAMP_18)

RH007/(TIMING) . 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 -1

DON’T KNOW -2

(TIME_STAMP_18) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

RH015. These next questions are about any previous pregnancies you may have had.

RH016/(PAST_PREG) . Before this pregnancy, have you ever been pregnant? Please include live births, miscarriages, stillbirths, ectopic pregnancies, abortions and pregnancy terminations.

Yes 1

No 2 (TIME_STAMP_19)

REFUSED -1 (TIME_STAMP_19)

DON’T KNOW -2 (TIME_STAMP_19)

RH0016A (NUM_PREG). Including this pregnancy, how many times total have you been pregnant?

|___|___|

Number

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: INCLUDE SOFT EDIT IF RESPONSE > 5

RH017/(AGE_FIRST) . How old were you when you became pregnant for the first time?

|___|___|

AGE IN YEARS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: INCLUDE SOFT EDIT IF RESPONSE < 13

RH018. Did any of your previous pregnancies end in the birth of a child more than 3 weeks early, before his or her due date?

Yes 1

No 2

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTIONS: INCLUDE INFANTS BORN ALIVE WHO LATER DIED. DO NOT INCLUDE MISCARRIAGES, STILLBIRTHS OR ABORTIONS.

RH019. Did any of your previous pregnancies end in a miscarriage or stillbirth?

Yes 1

No 2

REFUSED -1

DON’T KNOW -2

[Tobacco and alcohol Use]

(TIME_STAMP_19) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

DA001. The next questions are about your use of cigarettes and alcohol just before your current pregnancy.

DA002/(CIG_PAST) . In the 3 months before you knew you were pregnant, did you smoke any cigarettes?

Yes 1

No 2 DA011/(CIG_NOW).

REFUSED -1 DA011/(CIG_NOW).

DON’T KNOW -2 DA011/(CIG_NOW).

DA003 /(CIG_PAST_ FREQ). Did 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 -1

DON’T KNOW -2

DA004/(CIG_PAST_NUM) . On days that you smoked, how many cigarettes did you smoke per day? If you smoked 1 or less per day, enter “1.”

|___|___|

NUMBER PER DAY

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: INCLUDE SOFT EDIT IF RESPONSE > 60

IF RESPONSE IS IN PACKS, CALCULATE 20 CIGARETTES PER PACK

DA011/(CIG_NOW). Currently, do you smoke cigarettes?

Yes 1

No 2 (DA023)/(DRINK_PAST)

REFUSED -1 (DA023)/(DRINK_PAST)

DON’T KNOW -2 (DA023)/(DRINK_PAST))

DA012/(CIG_NOW_FREQ). 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 -1

DON’T KNOW -2

DA013/(CIG_NOW_NUM ). On days that you smoke, how many cigarettes do you smoke per day? If you smoke 1 or less per day, enter “1.”

|___|___|

NUMBER PER DAY

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: INCLUDE SOFT EDIT IF RESPONSE > 60

IF RESPONSE IS IN PACKS, CALCULATE 20 CIGARETTES PER PACK.

DA023/(DRINK_PAST). 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)/(DRINK_NOW)

REFUSED -1 (DA027) /(DRINK_NOW)

DON’T KNOW -2 (DA027) /(DRINK_NOW)

DA024/(DRINK_PAST_NUM). . 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 -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: INCLUDE SOFT EDIT IF RESPONSE > 5

DA025/(DRINK_PAST_5). . 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 -1

DON’T KNOW -2

DA027/(DRINK_NOW). . 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 (TIME_STAMP_20)

REFUSED -1 (TIME_STAMP_20)

DON’T KNOW -2 (TIME_STAMP_20)

DA028/(DRINK_NOW_NUM). .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 -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: INCLUDE SOFT EDIT IF RESPONSE > 5

DA029/(DRINK_NOW_5). . 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 -1

DON’T KNOW -2

INTERVIEWER INSTRUCTIONS: FOLLOW LOCAL MANDATORY REPORTING REQUIREMENTS.

[Evaluation Questions]

(TIME_STAMP_20) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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. (LEARN) Learning more about my health or the health of my child?	_____	_____	_____
b. (HELP) Feeling as if I can help children now and in the future?	_____	_____	_____
c. (INCENT) Receiving money or gifts for taking part in the study?	_____	_____	____
d. (RESEARCH) Helping doctors and researchers learn more about children and their health?	_____	_____	_____
e. (ENVIR) Helping researchers learn how the environment may affect children’s health?	_____	_____	_____
f. .(COMMUNITY) Feeling part of my community?	_____	_____	_____
g. (KNOW_OTHERS) Knowing other women in the study?	_____	_____	_____
h. (FAMILY) Having family members or friends support my choice to take part in the study?	_____	_____	_____
i. (DOCTOR) Having my doctor or health care provider support my choice to take part in the study?	_____	_____	_____
j. (STAFF) Feeling comfortable with the study staff who come to my home?	_____	_____	_____

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. (OPIN_FAMILY Your other family members	_____	_____	_____	_____	_____	____
c. (OPIN_FRIEND) Your friends	_____	_____	_____	_____	_____	____
d. (OPIN_DR) Your doctor or health care provider	_____	_____	_____	_____	_____	____

EV005/(EXPERIENCE). 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

[THANK YOU; RETURN INSTRUCTIONS]

Thank you for participating in the National Children’s Study and for taking the time to complete this survey.

(TIME_STAMP_21) 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.