Form 29.1 Survey

OMB #: 0925-0593

Expiration Date: 07/31/2013

Pregnancy Visit 2, Phase II

ASSUME PREGNANCY VISIT 1 WAS

ADMINISTERED UNLESS NOTED

Recruitment Strategy Substudy

Event Name(s):

Pregnancy Visit 2 Instrument (EH, PB, HI)

Pregnancy Visit 2 Instrument (EH, PB, HI) – SAQ

Instrument Name(s) and Versions:

Pregnancy Visit 2 Instrument (EH, PB, HI) – 1.0

Pregnancy Visit 2 Instrument (EH, PB, HI) – SAQ – 1.0

Recruitment Groups:

Enhanced Household, Provider-Based, and High Intensity

Pregnancy Visit 2 Instrument and SAQ (EH, PB, HI)

TABLE OF CONTENTS

CAPI 1

INTERVIEW INTRODUCTION 1

CURRENT PREGNANCY INFORMATION 3

HOUSING CHARACTERISTICS 10

EMPLOYMENT 17

SOCIAL SUPPORT 17

HEALTH INSURANCE 19

TRACING QUESTIONS 20

SELF-ADMINISTERED QUESTIONAIRES 28

EVALUATION QUESTIONS 28

Pregnancy Visit 2 Instrument and SAQ (EH, PB, HI)

CAPI

INTERVIEW INTRODUCTION

(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 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/(NAME_CONFIRM). Is your name [INSERT RESPONDENT’S NAME] ?

YES 1 (IN003)/ (DOB_CONFIRM)

NO …………………………………………………………..2 (R_FNAME)(R_LNAME)

REFUSED ……………………………………………………. -1 (R_FNAME)(R_LNAME)

DON’T KNOW …………………………………………………-2 (R_FNAME)(R_LNAME)

IN002A. /(R_FNAME) (R_LNAME) What is your full name?

_________________________ _________________________

FIRST NAME LAST NAME

(R_FNAME) (R_LNAME)

REFUSED -1 (IN003)/(DOB_CONFIRM)

DON’T KNOW -2 (IN003)/(DOB_CONFIRM)

INTERVIEWER INSTRUCTIONS:

• IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS, ASK FOR INITIALS OR SOME OTHER NAME SHE WOULD LIKE TO BE CALLED

• CONFIRM SPELLING OF FIRST NAME IF NOT PREVIOUSLY COLLECTED AND OF LAST NAME FOR ALL RESPONDENTS.

IN003. /(DOB_CONFIRM) Is your birth date [RESPONDENT’S DATE OF BIRTH AS MM/DD/YYYY]?

YES……………………………………………………………… 1 (AGE_ELIG)

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

INTERVIEWER INSTRUCTIONS:

• IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB IS REQUIRED TO DETERMINE ELIGIBILITY

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

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED ………………………………………………………………-1

DON’T KNOW…………………………………………………………...-2

INTERVIEWER INSTRUCTION:

• IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB IS REQUIRED TO DETERMINE ELIGIBILITY

• 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

(AGE_ELIG)

PROGRAMMER INSTRUCTION:  BASED ON DOB_CONFIRM OR PERSON_DOB CALCULATE AGE. USING KNOWN LOCAL AGE OF MAJORITY DETERMINE IF SHE IS ELIGIBLE (AT LEAST AGE OF MAJORITY AND LESS THAN AGE 50); SET AGE_ELIG AS APPROPRIATE

RESPONDENT IS AGE-ELIGIBLE 1 (TIME_STAMP_2)

RESPONDENT IS YOUNGER THAN AGE OF MAJORITY 2 (END)

RESPONDENT IS OVER AGE 49 3 (TIME_STAMP_2)

AGE ELIGIBILITY IS UNKNOWN 4 (TIME_STAMP_2)

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

PROGRAMMER INSTRUCTIONS: IF RESPONDENT HAS REPORTED BEING PREGNANT WITH MULTIPLES FILL IN “BABIES’ AS APPROPRIATE THROUGHOUT INSTRUMENT

CP000. First, I’d like to update some information about 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, OFFER TO RESPONDENT AND GO TO CP001C/(LOSS_INFO).

• OTHERWISE GO TO TR009/(END_LOSS).

CP001C./(LOSS_INFO) 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?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

IF VALID RESPONSE PROVIDED (DATE_KNOWN)

REFUSED -1(CP004) /(DATE_KNOWN)

DON’T KNOW -2(CP004) /(DATE_KNOWN)

INTERVIEWER INSTRUCTION:

• ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR

• IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE

PROGRAMMER INSTRUCTIONS:

• CHECK REPORTED DUE DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:

  • IF DATE IS MORE THAN 9 MONTHS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 9 MONTHS FROM TODAY. RE-ENTER DATE.”

  • IF DATE IS MORE THAN 1 MONTH BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT OCCURRED MORE THAN A MONTH BEFORE TODAY. RE-ENTER DATE.”

  • IF VALID DUE DATE WAS PROVIDED, SET (DUE_DATE) = YYYYMMDD AS REPORTED; GO TO (DATE_KNOWN)

CP004a/(DATE_KNOWN). INTERVIEWER COMPLETED QUESTION

DID RESPONDENT GIVE DATE?

RESPONDENT GAVE COMPLETE DATE 1

RESPONDENT GAVE PARTIAL DATE 2

RESPONDENT ANSWERED ‘DON’T KNOW’ OR ‘REFUSED’

FOR ALL DATE ELEMENTS 3

CP007/(BPLAN_CHANGE). Has the place where you plan to deliver your [baby/babies] changed since we last spoke with you?

YES 1 (CP008) /(BIRTH_PLAN)

NO 2 (CP008) /(BIRTH_PLAN)

REFUSED -1 (DV003) /(DATE_VISIT)

DON’T KNOW -2 (CP008) /(BIRTH_PLAN)

CP008 /(BIRTH_PLAN). [So we make sure we have the correct information,] Where do you plan to deliver your [baby/babies]?

PROGRAMMER INSTRUCTION: IF (BPLAN_CHANGE) = 2 (NO); BEGIN WITH BRACKETED PHRASE

In a hospital, 1

A birthing center, 2

At home, or 3 (DV003) /(DATE_VISIT)

Some other place? 4

REFUSED -1 (DV003) /(DATE_VISIT)

DON’T KNOW -2 (DV003) /(DATE_VISIT)

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

_____________________________________________________

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

FY008. Are you using the Pregnancy Health Care Log? This is the booklet that you or your health care provider (doctor, midwife, nurse, etc.) uses to record information about your medical visits.

YES 1 (FY012)

NO 2

REFUSED 9--97 (DV003)

DON’T KNOW 9--98 (DV003)

FY009. Is that because…

You haven’t had a medical visit since our last interview, 1 (DV003)

You’ve misplaced the log, or 2 (FY010)

You’ve forgotten to bring it to your medical visits? 3 (FY011)

The log was too much trouble to complete, or 4 (FY011)

The log was too difficult to understand? 5 (DV003)

OTHER (SPECIFY): 6

REFUSED 9--97 (FY011)

DON’T KNOW 9—98 (FY011)

FY009A. OTHER: SPECIFY _____________________________________ (DV003)

FY010. We’ll get another Pregnancy Health Care Log in the mail to you today. (DV003)

FY011. This information is very important to the study. Please keep the log in a safe place and bring the log with you to all of your medical visits. (DV003)

FY012 How many health care providers have you seen since using this Pregnancy Health Care Log?

|___|___|

NUMBER OF PROVIDERS

REFUSED 9--97

DON’T KNOW 9--98

FY013 Of those providers that you seen, how many providers have you recorded their contact information such as address or phone number?

|___|___|

NUMBER OF CONTACTS

REFUSED 9--97

DON’T KNOW 9--98

DV001. I am now going to ask some questions about visits to a doctor or other health care provider (doctor, midwife, nurse, etc.). You may want to refer to the Pregnancy Health Care Log that you received as part of this study or to any other personal record or calendar that you keep that would help you to remember the dates of these visits. If you have this information available, please go and get it now.

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

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

HAVE NOT HAD A VISIT 1

REFUSED -1

DON’T KNOW -2

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

FY027. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Pregnancy Health Care Log.

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…”

INTERVIEWER INSTRUCTIONS: RE-READ INTRODUCTORY STATEMENT AS NEEDED

(DIABETES_1) Diabetes?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

[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?

(HIGHBP_PREG) High blood pressure?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(URINE) Protein in your urine?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(PREECLAMP) Preeclampsia or toxemia?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(EARLY_LABOR) Early or premature labor?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(ANEMIA) Anemia or low blood count?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(NAUSEA) Severe nausea or vomiting (hyperemesis)?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(KIDNEY) Bladder or kidney Infection?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(RH_DISEASE) Rh disease or isoimmunization?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(GROUP_B) Infection with a bacteria called Group B strep?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(HERPES) Infection with a Herpes virus?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(VAGINOSIS) Infection of the vagina with bacteria (Bacterial vaginosis?)

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(OTH_CONDITION) Any other serious condition?

YES………………………………………………………………………….. 1 (CONDITION_OTH)

NO 2

REFUSED -1

DON’T KNOW -2

DV014/(CONDITION_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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

YES 1 (ADMIN_DATE)

NO 2 (TIME_STAMP_5)

REFUSED -1 (TIME_STAMP_5)

DON’T KNOW -2 (TIME_STAMP_5)

DV018/(ADMIN_DATE). What was the admission date of your most recent hospital stay?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

HAVE NOT BEEN HOSPITALIZED OVERNIGHT/NOT APPLICABLE……….. -7 (TIME_STAMP_5)

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

DV019/(HOSP_NIGHTS). How many nights did you stay in the hospital during this hospital stay?

|___|___|___|

NUMBER OF NIGHTS

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: CONFIRM RESPONSE

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

YES 1

NO 2 (TIME_STAMP_5)

REFUSED -1 (TIME_STAMP_5)

DON’T KNOW -2 (TIME_STAMP_5)

DV021 /(DIAGNOSE_2).. What was the diagnosis?

SELECT ALL THAT APPLY.

DEHYDRATION 1

PRETERM LABOR 2

HYPEREMESIS 3

PREECLAMPSIA 4

RUPTURE OF MEMBRANES 5

KIDNEY DISORDER 6

OTHER -5 (DIAGNOSIS_OTH)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: PROBE FOR MULTIPLE RESPONSES

DV021A/ (DIAGNOSIS_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

FY027. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Pregnancy Health Care Log.

HOUSING CHARACTERISTICS

(TIME_STAMP_5) 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 (TIME_STAMP_6)

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW -2 (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

Occupied without payment of rent? 3

SOME OTHER ARRANGEMENT…………………………... -5 (OWN_HOME_OTH) 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 -5 (MAIN_HEAT _OTH)

REFUSED -1 (HC011)/(COOLING)

DON’T KNOW -2 (HC011)/(COOLING)

INTERVIEWER INSTRUCTION: SHOW RESPONSE OPTIONS ON CARD TO RESPONDENT

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 -5 (HEAT2_OTH)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO RESPONDENT.

• 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_6)

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW -2 (TIME_STAMP_6)

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 -5 (COOL_OTH)

REFUSED -1

DON’T KNOW -2

HC012A. (COOL_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_6) 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? -5 (WATER_DRINK_ OTH)

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? -5 (WATER_COOK_OTH)

REFUSED -1

DON’T KNOW -2

HC035A. (WATER_COOK_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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 -1

DON’T KNOW -2

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 (ROOM_MOLD)

NO 2 (TIME_STAMP_8)

REFUSED -1 (TIME_STAMP_8)

DON’T KNOW -2 (TIME_STAMP_8)

HC020. (ROOM_MOLD) In which rooms have you seen the mold or mildew?

INTERVIEWER INSTRUCTION, PROBE: Any other rooms?

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 -5 (ROOM_MOLD _OTH)

REFUSED -1

DON’T KNOW -2

HC020A. (ROOM_MOLD _OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_8) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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

HC022./(PRENOVATE2) 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)/(PDECORATE2)

REFUSED -1 (HC025)/(PDECORATE2)

DON’T KNOW -2 (HC025)/(PDECORATE2)

HC024. (PRENOVATE2_ROOM) Which rooms were renovated?

INTERVIEWER INSTRUCTION, 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 -5 (PRENOVATE2_ROOM_OTH)

REFUSED -1

DON’T KNOW -2

HC024A. (PRENOVATE2_ROOM_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC025. (PDECORATE2) 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 (TIME_STAMP_9)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

HC026. (PDECORATE2_ROOM)In which rooms were these smaller projects done?

INTERVIEWER INSTRUCTION, 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 -5 (PDECORATE2_ROOM_OTH)

REFUSED -1

DON’T KNOW -2

HC026A. (PDECORATE2_ROOM_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

EMPLOYMENT

(TIME_STAMP_9) 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 (TIME_STAMP_10)

REFUSED -1 (TIME_STAMP_10)

DON’T KNOW -2 (TIME_STAMP_10)

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

SOCIAL SUPPORT

(TIME_STAMP_10) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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.

INTERVIEWER INSTRUCTION: USE SHOW CARD WITH RESPONSE CATEGORIES

SS001/(LISTEN). Is there someone available to you whom you can count on to listen to you when you need to talk? Would you say…

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 -1

DON'T KNOW -2

SS002/(ADVICE). Is there someone available to give you good advice about a problem?

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 -1

DON'T KNOW -2

SS003/(AFFECTION) Is there someone available to you who shows you love and affection?

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 -1

DON'T KNOW -2

SS004/(DAILY_HELP) Is there someone available to help you with daily chores?

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 -1

DON'T KNOW -2

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

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 -1

DON'T KNOW -2

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

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 -1

DON'T KNOW -2

HEALTH INSURANCE

(TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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/(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_12)

REFUSED -1 (TIME_STAMP_12)

DON’T KNOW -2 (TIME_STAMP_12)

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

CURRENTLY have.

Do you currently have…

INTERVIEWER INSTRUCTIONS: RE-READ INTRODUCTORY STATEMENT AS NEEDED

(INS_EMPLOY) Insurance through an employer or union either through yourself or another family member?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_MEDICAID) Medicaid or any government-assistance plan for those with low incomes or a disability?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTIONS: PROVIDE EXAMPLES OF LOCAL MEDICAID PROGRAMS

(INS_TRICARE) TRICARE, VA, or other military health care?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_IHS) Indian Health Service?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_MEDICARE) Medicare, for people with certain disabilities?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_OTH) Any other type of health insurance or health coverage plan?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

TRACING QUESTIONS

(TIME_STAMP_12) 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.

TR100/(COMM_EMAIL) . 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 2 (COMM_CELL)

DON’T REMEMBER 3

REFUSED -1

DON’T KNOW -2

TR101. (HAVE_EMAIL)

[IF COMM_EMAIL=1] Do you have an email address?

[IF COMM_EMAIL = 3,-1,OR -2] So that I can make sure I have your latest information, do you have an email address?

YES 1

NO 2 (COMM_CELL)

REFUSED -1 (COMM_CELL)

DON’T KNOW -2 (COMM_CELL)

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 the best email address to reach you?

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

ENTER E-MAIL ADDRESS: ___________________________________

REFUSED -1

DON’T KNOW -2

TR104a/(COMM_CELL). 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 2 (TIME_STAMP_13)

DON’T REMEMBER 3

REFUSED -1

DON’T KNOW -2

TR105. (CELL_PHONE_1)

[IF (COMM_CELL) =1] Do you have a personal cell phone?

[IF (COMM_CELL) = 3, -1, -2] So that I can make sure I have your latest information, do you have a personal cell phone?

YES 1

NO 2 (TIME_STAMP_13)

REFUSED -1 (TIME_STAMP_13) DON’T KNOW -2 (TIME_STAMP_13) )

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 (CELL_PHONE)

REFUSED -1 (CELL_PHONE)

DON’T KNOW -2 (CELL_PHONE)

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

RESPONDENT HAS NO CELL PHONE 1

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_13) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TR001/(COMM_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 2 (TR010)/(END)

DON’T REMEMBER 3

REFUSED -1

DON’T KNOW -2

TR001a/(CONTACT_1).

[IF COMM_CONTACT =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 COMM_CONTACT = 3, -1, -2] 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)/(END)

REFUSED -1 (TR010)/(END)

DON’T KNOW -2 (TR010)/(END)

TR002/(CONTACT_fNAME_1)/(CONTACT_lnAME_1). What is this person’s name?

______________ __________________

FIRST NAME LAST NAME

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

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

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TR014/(CONTACT_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 (CONTACT_RELATE1 _OTH) -5

REFUSED -1

DON’T KNOW -2

Tr014a/(CONTACT_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 (C_aDDR1_1)/(C_aDDR2_1)/(C_uNIT_1)

____________________________________________________

CITY (C_CITY_1)

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

STATE ZIP CODE

(C_sTATE_1) (C_zIPCODE_1) (C_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

(CONTACT_FNAME_2) (CONTACT_LNAME_2)

NO SECOND CONTACT PROVIDED 1 (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/(CONTACT_RELATE_2). What is his/her relationship to you?

MOTHER/FATHER 1

BROTHER/SISTER 2

AUNT/UNCLE 3

GRANDPARENT 4

NEIGHBOR 5

FRIEND 6

OTHER -5 (CONTACT_relatE2_oth)

REFUSED -1

DON’T KNOW -2

tr006a/(CONTACT_relatE2_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 (C_aDDR1_2)/(C_aDDR_2_2)/(C_UNIT_2)

_____________________________________________________

CITY (C_cITY_2)

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

STATE ZIP CODE

(C_sTATE_2) (C_zIPcode_2) (C_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

REFUSED -1

DON’T KNOW -2

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.

INTERVIEWER INSTRUCTION: END INTERVIEW. DO NOT ADMINISTER SAQs.

TR010/(END)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.

INTERVIEWER INSTRUCTION: explain SAQS and RETURN process

(TIME_STAMP_14) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

SELF-ADMINISTERED QUESTIONAIRES

EVALUATION QUESTIONS

VISIT EVALUATION QUESTIONS MAY BE COMPLETED IN EITHER PAPI OR CASI MODE.

INTERVIEWER INSTRUCTIONS: IF SAQ is COMPLETED AS A PAPI, RECORD THE PARTICIPANT’S ID TO TOP OF INSTRUMENT

(TIME_STAMP_15) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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

(LEARN) (How important was…) Learning more about my health or the health of my child?

Not at all important 1

Somewhat important 2

Very important 3

(HELP) (How important was…) Feeling as if I can help children now and in the future?

Not at all important 1

Somewhat important 2

Very important 3

(INCENT) (How important was…) Receiving money or gifts for taking part in the study?

Not at all important 1

Somewhat important 2

Very important 3

(RESEARCH) (How important was…) Helping doctors and researchers learn more about children and their health?

Not at all important 1

Somewhat important 2

Very important 3

(ENVIR) (How important was…) Helping researchers learn how the environment may affect children’s health?

Not at all important 1

Somewhat important 2

Very important 3

(COMMUNITY) (How important was…) Feeling part of my community?

Not at all important 1

Somewhat important 2

Very important 3

(KNOW_OTHERS) (How important was…) Knowing other women in the study?

Not at all important 1

Somewhat important 2

Very important 3

(FAMILY) (How important was…) Having family members or friends support my choice to take part in the study?

Not at all important 1

Somewhat important 2

Very important 3

(DOCTOR) (How important was…) Having my doctor or health care provider support my choice to take part in the study?

Not at all important 1

Somewhat important 2

Very important 3

(STAFF) (How important was…) Feeling comfortable with the study staff who come to my home?

Not at all important 1

Somewhat important 2

Very important 3

EV004. How negative or positive do each of the following people feel about you taking part in the National Children’s Study?

(OPIN_SPOUSE) Your spouse or partner

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

(OPIN_FAMILY) Other family members

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

(OPIN_FRIEND) Your friends

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

(OPIN_DR) Your doctor or health care provider

Very Negative 1

Somewhat Negative 2

Neither Positive or Negative 3

Somewhat Positive 4

Very Positive 5

Not Applicable 6

EV005/(EXPERIENCE). In general, has your experience with the National Children’s Study been

Mostly negative 1

Somewhat negative 2

Neither negative nor positive 3

Somewhat positive 4

Mostly positive 5

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 1

A little 2

Some 3

A lot 4

EV008./(INT_LENGTH) Did you think the interview was

Too short 1

Too long, or 2

Just about right? 3

EV009./(INT_STRESS) Do you think the interview was

Not at all stressful 1

A little stressful 2

Somewhat stressful, or 3

Very stressful? 4

EV010./(INT_REPEAT) If you were asked, would you participate in an interview like this again?

Yes 1

No 2

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

[IF SAQ IS COMPLETED AS A PAPI, SCs MUST PROVIDE INSTRUCTIONS AND A BUSINESS REPLY ENVELOPE FOR RESPONDENT TO RETURN]

(TIME_STAMP_16) 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.