Form 7 Survey

OMB #: 0925-0593

Expiration Date: xx/xxxx

JULY LAUNCH VERSION

VERSION 6/7/2010

ASSUME PREGNANCY VISIT 1 WAS

ADMINISTERED UNLESS NOTED

Recruitment Strategy Substudy

Pregnancy Visit 2 Interview

TABLE OF CONTENTS

CAPI

INTERVIEW INTRODUCTION

CURRENT PREGNANCY INFORMATION

HOUSING CHARACTERISTICS …………………………………………………………………..

EMPLOYMENT

SOCIAL SUPPORT

HEALTH INSURANCE

TRACING QUESTIONS

SELF-ADMINISTERED QUESTIONNAIRES

INTERVIEW EVALUATION

DOCUMENT HISTORY

DATE	VERSION	SUMMARY OF CHANGE/MILESTONE
4/14/2010	20100402	INITIAL DRAFT BY SCHOENDORF AND TANEJA
4/21/2010	SAQ – Time Place and Activity Diary Revised	REVISED TIME PLACE AND ACTIVITY DIARY
NA	NA	COMMENTS FROM HIRSCHFELD
4/23/2010	20100422	INFORMAL SUBMISSION TO OMB
5/20/2010	20100519.kcs	INCORPORATE COMMENTS FROM SCs
5/21/2010	Compared Document	COMPARED DOCUMENT VERSIONS 20100422 AND 20100519.kcs
5/21/2010	20100519_jj	INCORPORATE VARIABLE SOURCES
5/23/2010	20100521	INCORPORATE COMMENTS FROM OMB
5/27/2010	20100527	REVISED INTERVIEW INTRODUCTORY TEXT AND ADDED CLOSING SCRIPT
6/4/2010	20100602	INCORPORATE COMMENTS FROM THE NCS PROGRAM OFFICE, PULL VARIABLES FROM THE PRE-PREGNANCY INTERVIEW FOR LIKE QUESTIONS, AND HIGHLIGHT ELIGIBILITY LANGUAGE (NONE FOUND)
6/7/2010	20100607	INCORPORATE CHANGES FROM J. PARK
6/7/2010	20100607a	INCORPORATE CHANGES FROM J. SLUTSMAN
		RECONCILE WITH DATA ELEMENTS TABLES
		FORMAL SUBMISSION TO OMB
		INCORPORATE COMMENTS FROM OMB
		SUBMIT TO NICHD IRB
		RECONCILE WITH DATA ELEMENTS TABLES

NOTE: Italics denote anticipated development stages

CAPI

INTERVIEW INTRODUCTION

IN001. Thank you for agreeing to participate in the National Children’s Study. This interview will take about 20 minutes to complete. Your answers are important to us. There are no right or wrong answers.We will ask you questions about yourself, your health and pregnancy, your feelings and attitudes, and where you live. 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. Is your name ____[PRELOAD]_____________________ ?

YES 1 (IN003)

NO 2 (IN002A)

IN002A. What is your full name?

_________________________

IN003. Is your birth date DD/MM/YYYY?

YES 1 (CP000)

NO 2 (IN003A)

IN003A. What is your correct birth date?

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

YYYY MM DD

CURRENT PREGNANCY INFORMATION

CP000. First, I’d like to update some information about about your current pregnancy.

CP001. The first questions ask about how your pregnancy is progressing. First, are you still

pregnant?

YES 1 (CP002)

NO 2 (CP001A)

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.

PROGRAMMING NOTE - LOCAL OPTION – if Center has pregnancy loss information to disseminate, go to CP001C. Otherwise go to TR009.

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

YES 1 (TR009)

NO 2 (TR009)

CP002. What is your current due date?

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

YYYY MM DD

REFUSED 9—97 (CP004)

DON’T KNOW 9—98 (CP004)

CP004a. DID RESPONDENT GIVE DATE?

RESPONDENT GAVE COMPLETE DATE 1

INTERVIEWER ENTERED 15 FOR DAY 2

CP007. Has the place where you plan to deliver your baby changed since we last spoke with you?

YES 1 (CP008)

NO 2 (CP008)

REFUSED 9—97 (DV003)

DON’T KNOW 9—98 (CP008)

CP008. {So we make sure we have the correct information}, Where do you plan to deliver your baby:

INTERVIEWER or PROGRAMMER INSTRUCTION – if place to deliver baby has changed (CP007 = 1) then read phrase in brackets. Otherwise, omit.

In a hospital, 1

A birthing center, 2

At home, or 3 (DV003)

Some other place? 4

REFUSED 9—97 (DV003)

DON’T KNOW 9—98 (DV003)

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

_____________________________________________________

NAME OF BIRTH HOSPITAL/BIRTHING CENTER

_____________________________________________________

STREET ADDRESS

_____________________________________________________

CITY

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

STATE ZIP CODE

REFUSED 9—97

DON’T KNOW 9—98

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

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

YYYY MM DD

HAVE NOT HAD A VISIT 6 (DV017)

REFUSED 9—97 (DV017)

DON’T KNOW 9—98 (DV017)

DV013. At this visit or at any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?

YES NO RF DK

a. Diabetes? 1 2 9--97 9--98

b. High blood pressure? 1 2 9--97 9--98

c. Protein in your urine? 1 2 9--97 9--98

d. Preeclampsia or toxemia? 1 2 9--97 9--98

e. Early or premature labor? 1 2 9--97 9--98

f. Anemia or low blood count? 1 2 9--97 9--98

g. Severe nausea or vomiting (hyperemesis)? 1 2 9--97 9--98

h. Bladder or kidney Infection 1 2 9--97 9--98

i. Rh disease or isoimmunization? 1 2 9--97 9--98

j. Infection with a bacteria called Group B strep? 1 2 9--97 9--98

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

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

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

DV014. (CONDITION_OTH)

SPECIFY _____________________________

REFUSED

DON’T KNOW

DV017. Since you’ve been pregnant, have you spent at least one night in the hospital?

YES 1

NO 2 (HC000)

REFUSED 9--97 (HC000)

DON’T KNOW 9--98 (HC000)

DV018. What was the admission date of your most recent hospital stay?

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

YYYY MM DD

REFUSED 9--97

DON’T KNOW 9--98

DV019. How many nights did you stay in the hospital during this hospital stay?

|___|___|___|

NUMBER OF NIGHTS

REFUSED 9--97

DON’T KNOW 9--98

DV020. Did a doctor or other health care provider give you a diagnosis during this hospital stay?

YES 1

NO 2 (HC000)

REFUSED 9--97 (HC000)

DON’T KNOW 9--98 (HC000)

DV021. What was the diagnosis?

SELECT ALL THAT APPLY.

DEHYDRATION 01

PRETERM LABOR 02

HYPEREMISIS 03

PREECLAMPSIA 04

RUPTURE OF MEMBRANES 05

KIDNEY DISORDER 06

OTHER (DIAGNOSIS_OTH) -5

REFUSED 9—97

DON’T KNOW 9—98

DV021A. (DIAGNOSIS_OTH)

SPECIFY _____________________________

REFUSED 9—97

DON’T KNOW 9—98

Housing Characteristics

(TIME_STAMP_1) 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.

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

YES 1 (HC002)/(OWN_HOME)

NO 2

REFUSED -1

DON’T KNOW -2

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

SKIP TO TIME_STAMP_8.

ELSE IF RECENT_MOVE IN (1, -2) 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) 6

REFUSED 9—97

DON’T KNOW 9—98

HC002A. (OWN_HOME_OTH)

SPECIFY _____________________________

REFUSED

DON’T KNOW

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 9—97

DON’T KNOW 9—98

HC005. (LENGTH_RESIDE)/(LENGTH_RESIDE_UNIT) How long have you lived in this home?

|___|___|

NUMBER

WEEKS 1

MONTHS 2

YEARS 3

REFUSED 9—97

DON’T KNOW 9—98

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?

[NEED SHOW CARD]

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 9—97 (HC011)/(COOLING)

DON’T KNOW 9—98 (HC011)/(COOLING)

HC007A. (MAIN_HEAT _OTH)

SPECIFY _____________________________

REFUSED

DON’T KNOW

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?

[NEED SHOW CARD]

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 9—97

DON’T KNOW 9—98

HC008A. (HEAT2_OTH)

SPECIFY _____________________________

REFUSED 9—97

DON’T KNOW 9—98

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

YES 1

NO 2 (HC017)

REFUSED 9—97 (HC017)

DON’T KNOW 9—98 (HC017)

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 9—97

DON’T KNOW 9—98

HC012A. (COOL_OTH)

SPECIFY _____________________________

REFUSED 9—97

DON’T KNOW 9—98

(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 9—97

DON’T KNOW 9—98

HC034A. (WATER_DRINK_ OTH)

SPECIFY _____________________________

REFUSED 9—97

DON’T KNOW 9—98

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 9—97

DON’T KNOW 9—98

HC035A. (WATER_COOK_OTH)

SPECIFY _____________________________

REFUSED 9—97

DON’T KNOW 9—98

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)Since we last spoke with you, have you seen any water damage inside your home?

YES 1

NO 2

REFUSED 9—97

DON’T KNOW 9—98

HC019. (MOLD)Since we last spoke with you, 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 (HC021)

REFUSED 9—97 (HC021)

DON’T KNOW 9—98 (HC021)

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 9—97

DON’T KNOW 9—98

HC020A. (ROOM_MOLD _OTH)

SPECIFY _____________________________

REFUSED 9—97

DON’T KNOW 9—98

(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)Since we last spoke with you, 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 refinishing floors.

YES 1

NO 2 (HC025)/(DECORATE)

REFUSED 9—97 (HC025)/(DECORATE)

DON’T KNOW 9—98 (HC025)/(DECORATE)

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 9—97

DON’T KNOW 9—98

HC024A. (RENOVATE_ROOM_OTH)

SPECIFY _____________________________

REFUSED 9—97

DON’T KNOW 9—98

HC025. Since we last spoke with you, were any smaller projects done in your home, such as painting, wallpapering, refinishing floors, or installing new carpet?

YES 1

NO 2 (HC033)

REFUSED 9—97 (HC033)

DON’T KNOW 9—98 (HC033)

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 9—97

DON’T KNOW 9—98

HC026A. (DECORATE_ROOM_OTH)

SPECIFY _____________________________

REFUSED 9—97

DON’T KNOW 9—98

EMPLOYMENT

(TIME_STAMP_9A) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

OH000. Now, I’d like to ask some questions about your current employment status.

OH000A. 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.

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

YES 1

NO 2 (SS000)

REFUSED 9—97 (SS000)

DON’T KNOW 9—98 (SS000)

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

|___|___|___|

NUMBER OF HOURS

REFUSED 9—97

DON’T KNOW 9—98

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

YES 1

NO 2

SOMETIMES 3

REFUSED 9—97

DON’T KNOW 9—98

SOCIAL SUPPORT

SS000. The following questions ask about your feelings and thoughts during the last month. For the following questions, please refer to the card and choose the answer that best describes your life now.

SHOW CARD SS1

SS001. Is there someone available to you whom you can count on to listen to you when you need to talk:?

None of the time 1

A little of the time 2

Some of the time 3

Most of the time 4

All of the time 5

REFUSED 9—97

DON'T KNOW 9—98

SS002. Is there someone available to give you good advice about a problem?

SHOW CARD SS1

NONE OF THE TIME 1

A LITTLE OF THE TIME 2

SOME OF THE TIME 3

MOST OF THE TIME 4

ALL OF THE TIME 5

REFUSED 9—97

DON'T KNOW 9—98

SS003. Is there someone available to you who shows you love and affection?

[SHOW CARD SS1]

NONE OF THE TIME 1

A LITTLE OF THE TIME 2

SOME OF THE TIME 3

MOST OF THE TIME 4

ALL OF THE TIME 5

REFUSED 9—97

DON'T KNOW 9—98

SS004. Is there someone available to help you with daily chores?

SHOW CARD SS1

NONE OF THE TIME 1

A LITTLE OF THE TIME 2

SOME OF THE TIME 3

MOST OF THE TIME 4

ALL OF THE TIME 5

REFUSED 9—97

DON'T KNOW 9—98

SS005. Can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?

SHOW CARD SS1

NONE OF THE TIME 1

A LITTLE OF THE TIME 2

SOME OF THE TIME 3

MOST OF THE TIME 4

ALL OF THE TIME 5

REFUSED 9—97

DON'T KNOW 9—98

SS006. Do you have as much contact as you would like with someone you feel close to, someone in whom you can trust and confide?

SHOW CARD SS1

NONE OF THE TIME 1

A LITTLE OF THE TIME 2

SOME OF THE TIME 3

MOST OF THE TIME 4

ALL OF THE TIME 5

REFUSED 9—97

DON'T KNOW 9—98

HEALTH INSURANCE

HI000. Now I’m going to switch the subject and ask about health insurance. The next questions

are similar to those asked the last time we contacted you, but we are asking them again because sometimes the answers change.

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

YES 1

NO 2 (HC000)

REFUSED 9—97 (HC000)

DON’T KNOW 9—98 (HC000)

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

currently have.

(Do you currently have:)

YES NO RF DK

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

another family member? 1 2 9—97 9—98

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

or a disability? 1 2 9—97 9—98

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

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

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

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

TRACING QUESTIONS

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.

TR100. When we last spoke with you, we asked questions about communicating with you through personal email. Have your preferences regarding contacting you via personal email changed since then?

Yes 1

No, or 2 (TR104a)

You don’t remember? 3

REFUSED 9—97

TR101. (HAVE_EMAIL) {IF TR100=1} Do you have a personal email address?

{IF TR100 = 3} So that I can make sure I have your latest information, do you have a

personal email address?

YES 1

NO 2 (TR104a)

REFUSED 9—97 (TR104a)

DON’T KNOW 9—98 (TR104a)

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

YES 1

NO 2

REFUSED 9—97

DON’T KNOW 9—98

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 9—97

DON’T KNOW 9—98

TR104. What is your personal email address?

____________________________________________________

REFUSED 9—97

DON’T KNOW 9—98

TR104a. At our last contact we asked questions about communicating with you through your

personal cell phone. Have your preferences regarding contacting you via cell phone

changed since then?

Yes 1

No, or 2 (TR001)

You don’t remember? 3

REFUSED 9—97

TR105. (CELL_PHONE_1) {IF TR104a=1} Do you have a personal cell phone?

{IF TR104a = 3} So that I can make sure I have your latest information, do you have a

personal cell phone?

YES 1

NO 2 (TR001)/(CONTACT)

REFUSED 9—97 (TR001)/(CONTACT)

DON’T KNOW 9—98 (TR001)/(CONTACT)

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 9—97

DON’T KNOW 9—98

TR107. (CELL _PHONE_3) Do you send and receive text messages on your personal cell phone?

YES 1

NO 2 (TR001)

REFUSED 9—97 (TR001)

DON’T KNOW 9—98 (TR001)

TR108. (CELL _PHONE_4) May we send text messages to make future study appointments

or for appointment reminders?

YES 1

NO 2

REFUSED 9—97

DON’T KNOW 9—98

TR109. (CELL _PHONE) What is your personal cell phone number?

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

PHONE NUMBER

NONE 9—91

REFUSED 9—97

DON’T KNOW 9—98

TR001. (CONTACT) 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, or 2 (EOS)

You don’t remember? 3

DON’T KNOW 9—98

TR001a. {IF TR001=1} 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?

{IF TR001 = 3} So that I can make sure I have your latest information, 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 (TR010)

REFUSED 9—97 (TR010)

DON’T KNOW 9—98 (TR010)

TR002. (f_NAME_1)/(l_nAME_1). What is this person’s name?

______________ __________________

FIRST NAME LAST NAME

REFUSED 9--97 (TR010)

DON’T KNOW 9--98 (TR010)

INTERVIEWER INSTRUCTION:

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 (RELATE_1 _OTH) -5

REFUSED 9—97

DON’T KNOW 9—98

Tr014a. (RELATE_OTH)

SPECIFY _____________________________

REFUSED 9—97

DON’T KNOW 9—98

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

INTERVIEWER INSTRUCTIONS:

PROMPT AS NECESSARY TO COMPLETE INFORMATION

____________________________________________________

STREET (aDDR1_1)/(aDDR2_1)/(uNIT_1)

____________________________________________________

CITY (CITY_1)

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

STATE ZIP CODE

(sTATE_1) (zIPCODE_1) (zIP4_1)

REFUSED 9--97

DON’T KNOW 9—98

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

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

PHONE NUMBER

NONE 9—91

REFUSED 9—97

DON’T KNOW 9—98

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 9--91 (TR010)

REFUSED 9--97 (TR010)

DON’T KNOW 9--98 (TR010)

INTERVIEWER INSTRUCTION: 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 (relatE2_oth) -5

REFUSED 9—97

DON’T KNOW 9—98

tr006a. (relatE2_oth)

SPECIFY _____________________________

REFUSED 9—97

DON’T KNOW 9—98

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 9—97

DON’T KNOW 9—98

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

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

PHONE NUMBER

NONE 9—91

REFUSED 9—97

DON’T KNOW 9—98

TR009.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. Thank you for participating in the National Children’s Study and for taking the time to answer our questions.This concludes the interview portion of our visit.

[explain SAQS and RETURN process]

SELF-ADMINISTERED QUESTIONAIRES

[TIME, PLACE, AND ACTIVITY DIARY; SEE separate document]

[Evaluation Questions]

[QUESTIONS NEED FORMATTING, RE-WORDING FOR SAQ; HEADERS REMOVED]

[INTRODUCTION]

IN001. Thank you for agreeing to participate in this study. This self-administered questionnaire will take about 5 minutes to complete. 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.

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 about 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
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 (GO TO 6)

• Mostly positive (GO TO 6)

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.

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.