Form 42.1 Survey

OMB Control Number: 0925-0593

OMB Expiration Date: 07/31/ 2013

3-Month Mother Phone Interview, Phase II

Recruitment Strategy Substudy

Event Name(s):

3-Month Mother Phone Interview (EH, PB, HI)

Instrument Name(s) and Versions:

3-Month Mother Phone Interview (EH, PB, HI) – 1.0

Recruitment Groups:

Enhanced Household, Provider-Based, High Intensity

3-Month Mother Phone Interview (EH, PB, HI)

TABLE OF CONTENTS

INTERVIEW INTRODUCTION 3

participant verification 5

DEMOGRAPHICS 7

Sleep 11

CRYING PATTERNS 13

Child development and parenting 15

Child care arrangements 20

HEALTH care 22

Interview Introduction

IN001 (TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IN003 Hello. I’m [INTERVIEWER NAME] calling from the National Children’s Study. I’m calling today to ask you some questions about you and your baby. We realize that you are busy, and this call should take only about 20 minutes. I will ask you questions about your baby’s health and behavior and your household. Your answers are very important to us. There are no right or wrong answers. You can skip over any question or stop the interview at any time. We will keep everything that you tell us confidential.

INTERVIEWER COMPLETED QUESTIONS

IN005 (MULT_CHILD) IS THERE MORE THAN ONE CHILD IN THIS HOUSEHOLD ELIGIBLE FOR THE 3-MONTH CALL TODAY?

YES	…………………………………………………….	1
NO	…………………………………………………….	2

IN006 (CHILD_NUM) HOW MANY CHILDREN IN THIS HOUSEHOLD ARE ELIGIBLE FOR THE 3-MONTH CALL TODAY?

|___|___|

NUMBER OF CHILDREN

PROGRAMMER INSTRUCTION: IF MULT_CHILD = 1, COMPLETE QUESTIONNAIRE FOR EACH ELIGIBLE CHILD RECORDED IN CHILD_NUM

IN011 (CHILD_QNUM) WHICH NUMBER CHILD IS THIS QUESTIONNAIRE FOR?

|___|___|

PROGRAMMER INSTRUCTION: CHILD_QNUM CANNOT BE GREATER THAN CHILD_NUM

IN017 (CHILD_SEX) IS {CHILD_QNUM} A BOY OR GIRL?

BOY	…………………………………………………….	1
GIRL	…………………………………………………….	2

PROGRAMMER INSTRUCTION: USE CHILD_SEX TO CODE {his/her} AND {he/she} FIELDS AS APPROPRIATE THROUGHOUT INSTRUMENT

IN018 (RESP_REL) WHAT IS THE RELATIONSHIP OF RESPONDENT TO CHILD?

MOTHER	…………………………………………………….	1
FATHER	…………………………………………………….	2

OTHER…………………………………………………………….3 (RESP_REL_OTH)

(RESP_REL_OTH) SPECIFY____________________________________

Participant Verification

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

PV001 (CNAME_CONFIRM). Is your baby’s name _____[INSERT NAME]___________?

YES	…………………………………	1	(CDOB_CONFIRM)
NO	…………………………………	2	(C_FNAME)(C_LNAME)
REFUSED	…………………………………	-1	(C_FNAME)(C_LNAME)
DON’T KNOW	…………………………………	-2	(C_FNAME)(C_LNAME)

PROGRAMMER INSTRUCTION: INSERT CHILD’S NAME IF KNOWN

PV004 (C_FNAME) (C_LNAME) What is your baby’s full name?

_________________________ _________________________

FIRST NAME LAST NAME

(C_FNAME) (CHILD_LNAME)

REFUSED	…………………………………	-1	(CDOB_CONFIRM)
DON’T KNOW	…………………………………	-2	(CDOB_CONFIRM)

INTERVIEWER INSTRUCTIONS:

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

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

• IF C_FNAME AND C_LNAME=-1 or -2, SUBSTITUTE “YOUR CHILD” FOR C_FNAME IN REMAINER OF QUESTIONNAIRE.

PV007 (CDOB_CONFIRM). Is {C_FNAME/YOUR CHILD}’S birth date [INSERT CHILD’S DATE OF BIRTH]?

YES	…………………………………	1	(TIME_STAMP2)
NO	…………………………………	2	(CHILD_DOB)
REFUSED	…………………………………	-1	(CHILD_DOB)
DON’T KNOW	…………………………………	-2	(CHILD_DOB)

PROGRAMMER INSTRUCTIONS:

• PRELOAD CHILD’S DOB IF KNOWN AS MM/DD/YYYY

• IF RESPONSE = YES, SET CHILD_DOB TO KNOWN VALUE

INTERVIEWER INSTRUCTION: IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB HELPS DETERMINE ELIGIBILITY

PV011 (CHILD_DOB). What is {C_FNAME/YOUR CHILD}’s date of birth?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED	…………………………………	-1	(TIME_STAMP2)
DON’T KNOW	…………………………………	-2	(TIME_STAMP2)

INTERVIEWER INSTRUCTIONS:

• IF RESPONDENT REFUSES TO PROVIDE INFORMATION, RE-STATE CONFIDENTIALITY PROTECTIONS AND THAT DOB HELPS 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 INSTRUCTIONS:

• INCLUDE A SOFT EDIT/WARNING IF CALCULATED AGE IS LESS THAN 2 MONTHS OR GREATER THAN 5 MONTHS

• FORMAT CHILD_DOB AS YYYYMMDD

PV013 (TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS:

• IF CHILD_NUM = 1 AND IF ((NO PRIOR MATERNAL QUESTIONNAIRES WERE COMPLETED) OR (THE MOTHER WAS FIRST IDENTIFIED AT THE BIRTH VISIT)), GO TO MARISTAT

• IF MOTHER WAS ENROLLED PRIOR TO OR DURING PREGNANCY AND HAS COMPLETED AT LEAST ONE QUESTIONNAIRE BEFORE BIRTH, GO TO TIME_STAMP_3

• IF CHILD_NUM >1, GO TO SLEEP_PLACE_1

Demographics

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

Married, 1 (EDUC)/(DE003)

Not married but living together with a partner 2 (EDUC)

Never been married, 3 (EDUC) Divorced, 4 (EDUC)

Separated, or 5 (EDUC)

Widowed? 6 (EDUC)

REFUSED -1 (EDUC)

DON’T KNOW -2 (EDUC)

INTERVIEWER INSTRUCTION: RECORD THE RESPONDENT’S CURRENT MARITAL STATUS

DM003 (EDUC) What is the highest degree or level of school you have completed?

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1 (ETHNICITY)

HIGH SCHOOL DIPLOMA OR GED 2 (ETHNICITY)

SOME COLLEGE BUT NO DEGREE 3 (ETHNICITY)

ASSOCIATE DEGREE 4 (ETHNICITY)

BACHELOR’S DEGREE (FOR EXAMPLE, BA, BS) 5 (ETHNICITY)

POST GRADUATE DEGREE (FOR EXAMPLE, MASTERS OR DOCTORAL) 6 (ETHNICITY)

REFUSED -1 (ETHNICITY)

DON’T KNOW -2 (ETHNICITY)

DE006 (ETHNICITY) Do you consider yourself to be Hispanic, or Latina?

YES 1 (RACE)

NO 2 (RACE)

REFUSED -1 (RACE)

DON’T KNOW -2 (RACE)

DE007 (RACE) What race do you consider yourself to be? You may select one or more.

PROBE: Anything else?

SELECT ALL THAT APPLY.

White, 1 (HH_PRIMARY_LANG)

Black or African American, 2 (HH_PRIMARY_LANG)

American Indian or Alaska Native, 3 (HH_PRIMARY_LANG)

Asian, or 4 (HH_PRIMARY_LANG)

Native Hawaiian or Other Pacific Islander? 5 (HH_PRIMARY_LANG)

SOME OTHER RACE? -5 RACE_OTH)

REFUSED -1 (HH_PRIMARY_LANG)

DON’T KNOW -2 (HH_PRIMARY_LANG)

INTERVIEWER INSTRUCTION: CODE “OTHER” ONLY IF VOLUNTEERED.

DE007A (RACE_OTH)

SPECIFY _____________________________ (HH_PRIMARY_LANG)

REFUSED -1 (HH_PRIMARY_LANG)

DON’T KNOW -2 (HH_PRIMARY_LANG)

Now I’m going to ask a few questions about your income. Family income is important in understanding the information we collect and is often used in scientific studies to compare groups of people who are similar. Please remember that all the information you share with us is confidential.

Please think about your total combined family income during [CURRENT YEAR – 1] for all members of the family.

DE010 (HH_MEMBERS) How many household members are supported by your total combined family income?

|___|___| (NUM_CHILD)

NUMBER

REFUSED -1 INCOME)

DON’T KNOW -2 INCOME)

PROGRAMMER INSTRUCTION: RESPONSE MUST BE > 0; INCLUDE A SOFT EDIT IF RESPONSE IS > 15

DM016 (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 (INCOME)

REFUSED -1 (INCOME)

DON’T KNOW -2 (INCOME)

PROGRAMMER INSTRUCTIONS:

• INCLUDE HARD EDIT IF RESPONSE > HH_MEMBERS

• INCLUDE SOFT EDIT IF RESPONSE > 10

DM019 (INCOME) Of these income groups, which category best represents your total combined family income during the last calendar year?

Less than $30,000 1 (TR001)/(TIME_STAMP_10)

$30,000 - $49,999 2 (TR001)/(TIME_STAMP_10)

$50,000 - $99,999 3 (TR001)/(TIME_STAMP_10)

$100,000 or more 4 (TR001)/(TIME_STAMP_10)

REFUSED -1 (TIME_STAMP_3) DON’T KNOW -2 (TIME_STAMP_3)

DM020 (TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

DM021 (HH_PRIMARY_LANG) What is the primary language spoken in your home?

ENGLISH 1

SPANISH 2

ARABIC 3

CHINESE 4

FRENCH 5

FRENCH CREOLE 6

GERMAN 7

ITALIAN 8

KOREAN 9

POLISH 10

RUSSIAN 11

TAGALOG 12

VIETNAMESE 13

URDU 14

PUNJABI 15

BENGALI 16

FARSI 17

OTHER -5 (PERSON_LANG_OTH)

REFUSED -1

DON’T KNOW -2

DM022 (PERSON_LANG_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

Sleep

I’ll begin by asking you about {C_FNAME/YOUR CHILD}’s sleeping habits.

SL001 (SLEEP_PLACE_1) Does your baby usually sleep in your bedroom or in a different room at night?

IN RESPONDENT’S ROOM 1

IN A DIFFERENT ROOM 2

BOTH IN RESPONDENT’S ROOM AND A

DIFFERENT ROOM 3

REFUSED -1

DON’T KNOW -2

SL003 (SLEEP_PLACE_2) What does {C_FNAME/YOUR CHILD} sleep in at night?

A bassinette, 1

A crib, 2

A co-sleeper, 3

In the bed or other place with you, or 4

In something else? (SLEEP_PLACE_2_OTH) 5

REFUSED -1

DON’T KNOW -2

SL004 (SLEEP_PLACE_2_OTH) OTHER SPECIFY

SL006 (SLEEP_POSITION_NIGHT) In what position do you most often lay {C_FNAME/YOUR CHILD} down to sleep at night? On his/her.

Side, 1

Stomach, or 2

Back? 3

REFUSED -1

DON’T KNOW -2

SL008 (SLEEP_HRS_DAY) Approximately how many hours does {C_FNAME/YOUR CHILD} sleep during the day?

|___|___|

HOURS

REFUSED -1

DON’T KNOW -2

SL010 (SLEEP_HRS_NIGHT) Approximately how many hours does {C_FNAME/YOUR CHILD} sleep at night?

|___|___|

HOURS

REFUSED -1

DON’T KNOW -2

SL012 (SLEEP_DIFFICULT) How often is your baby difficult when {he/she} is put to bed?

Most of the time, 1

Often, 2

Sometimes, 3

Rarely, or 4

Never? 5

REFUSED -1

DON’T KNOW -2

Crying Patterns

All babies fuss and cry sometimes. I’m now going to ask you some questions to get a better idea of your baby’s crying patterns.

CP001 (CRY_MORE) Compared to other babies, do you think {C_FNAME/YOUR CHILD} cries more, the same or less?

MORE 1

THE SAME 2

LESS 3

REFUSED -1

DON’T KNOW -2

CP003 (CRY_CONSOLE) Can you usually calm or console {C_FNAME/YOUR CHILD} when {he/she} cries?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CP005 (CRY_COLIC) Does {C_FNAME/YOUR CHILD} have episodes of colic, or times when {he/she} cries and can’t be calmed or consoled?

YES 1

NO (CRY_PROBLEM/CP009)

REFUSED -1 ( CRY_PROBLEM)

DON’T KNOW -2 ( CRY_PROBLEM)

CP007 (COLIC_FREQ) How often does {C_FNAME/YOUR CHILD} have episodes of colic, or times when {he/she} cries and can’t be calmed or consoled:

Every day, 1

Most days, 2

Sometimes, or 3

Rarely? 4

REFUSED -1

DON’T KNOW -2

CP009 (CRY_PROBLEM) Are you finding {C_FNAME/YOUR CHILD}’s crying to be a problem or upsetting?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

Child Development and Parenting

Even though {C_FNAME/YOUR CHILD} is only [INSERT AGE OF CHILD IN MONTHS] months old, {he/she} may show emotions or other actions. Overall, would you describe your baby as:

PROGRAMMER INSTRUCTION: USING CHILD_DOB CALCULATE CHILD’S AGE TO THE NEAREST MONTH AND PREFIL INTRODUCTORY STATEMENT ABOVE

CDP003 (CALM) Calm?

YES	…………………………………	1
NO	…………………………………	2
REFUSED	…………………………………	-1
DON’T KNOW	…………………………………	-2

CDP004 (WORRIED) Worried?

YES	…………………………………………………..	1
NO	…………………………………	2
REFUSED	…………………………………	-1
DON’T KNOW	…………………………………	-2

CDP005 (SOCIAL) Sociable or outgoing?

YES	…………………………………………………..	1
NO	…………………………………	2
REFUSED	…………………………………	-1
DON’T KNOW	…………………………………	-2

CDP006 (ANGRY) Angry?

YES	…………………………………………………..	1
NO	…………………………………	2
REFUSED	…………………………………	-1
DON’T KNOW	…………………………………	-2

CDP007 (SHY) Shy or quiet?

YES	…………………………………………………..	1
NO	…………………………………	2
REFUSED	…………………………………	-1
DON’T KNOW	…………………………………	-2

CDP008 (STUBBORN) Stubborn?

YES	…………………………………………………..	1
NO	…………………………………	2
REFUSED	…………………………………	-1
DON’T KNOW	…………………………………	-2

CDP009 (HAPPY) Happy?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

I’d like to ask about {C_FNAME/YOUR CHILD} and you. I will read you a list of things {C_FNAME/YOUR CHILD} may already do or may start doing when {he/she} gets older. Does {C_FNAME/YOUR CHILD}:

CDP011 (EYES_FOLLOW) Follow you with {his/her} eyes?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP012 (SMILE) Smile when you smile at {him/her}?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP013 (REACH_1) Try to get a toy that is out of reach?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP014 (FEED) Feed {him/herself} a cracker or cereal?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP015 (WAVE) Wave goodbye?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP016 (REACH_2) Reach for toys or food held to {him/her}?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP017 (GRAB) Grab an object like a block or rattle from you?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP018 (SWITCH_HANDS) Move a toy or block from one hand to the other?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP020 (PICKUP) Pick up a small object like a Cheerio or raisin?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP021 (HOLD) Hold two toys or blocks at a time, one in each hand?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP022 (SOUND_2) Turn towards a sound?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP023 (SOUND_3) Turn toward someone when they’re speaking?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP024 (SPEAK_1) Make sounds as though {he/she} is trying to speak?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP025 (SPEAK_2) Say mama or dada?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP026 (HEADUP) Keep head steady when sitting or held up?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP027 (ROLL_1) Roll over from stomach to back?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP028 (ROLL_2) Roll from back to stomach?

YES	…………………………………………………..	1
NO	…………………………………………………..	2
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

CDP028 (TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Child Care Arrangements

CC001 Next, I’d like to ask you about different types of child care {C_FNAME/YOUR CHILD} may receive from someone other than parents or guardians. This includes regularly scheduled care arrangements with relatives and non-relatives, and day care or early childhood programs, whether or not there is a charge or fee, but not occasional baby-sitting.

(CHILDCARE) Does {C_FNAME/YOUR CHILD} currently receive any regularly scheduled care from someone other than a parent or guardian. For example, from relatives, non-relatives, or a child care center or program?

YES 1

NO 2 (TIME_STAMP_5)

REFUSED -1 (TIME_STAMP_5)

DON’T KNOW -2 (TIME_STAMP_5)

CC003 (FAMILY_CARE_HRS) I’d like you to think about all the care {C_FNAME/YOUR CHILD} receives from relatives. For example, from grandparents, brothers or sisters, or any other relatives. (This includes all regularly scheduled care arrangements with relatives that happen at least weekly, but does not include occasional baby-sitting.)

Including all of these regular arrangements, how many total hours each week does {C_FNAME/YOUR CHILD} receive care from relatives?

|___|___|___|

HOURS

REFUSED -1

DON’T KNOW -2

CC005 (HOMECARE_HRS) I’d like you to think about all the regularly scheduled care your child receives on a weekly basis from non-relatives in a home setting. (This includes all regularly scheduled care arrangements with non-relatives that happen at least weekly, including home child care providers, regularly scheduled sitter arrangements, or neighbors. This does not include day care centers, early childhood programs, or occasional babysitting.)

Including all of these arrangements, how many total hours each week does {C_FNAME/YOUR CHILD} receive care from non-relatives in a home setting?

|___|___|___|

HOURS

REFUSED -1

DON’T KNOW -2

CC007 (DAYCARE_HRS) I’d like you to think about all the care your child receives from child care centers. For example, day care centers, early learning centers, nursery schools, and preschools. (This includes all regularly scheduled care arrangements in child care centers that happen at least weekly.)

Including all of these arrangements, how many total hours each week does {C_FNAME/YOUR CHILD} receive care at child care centers?

|___|___|___|

HOURS

REFUSED -1

DON’T KNOW -2

CC009 (TIME_STAMP_5) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Health Care

HC001 (C_HEALTH) Since {C_FNAME/YOUR CHILD} was born, would you say {his/her} health has been poor, fair, good, excellent?

POOR 1

FAIR 2

GOOD 3

EXCELLENT 4

REFUSED -1

DON’T KNOW -2

The next questions are about where {C_FNAME/YOUR CHILD} goes for health care.

HC003 (R_HCARE) First, what kind of place does {C_FNAME/YOUR CHILD} usually go to when {he/she} needs routine or well-child care, such as a check-up or well-baby shots (immunizations)?

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 WELL-CHILD CARE ANYWHERE	………………………	7	(HCARE_SICK)
REFUSED	………………………	-1	(HCARE_SICK)
DON’T KNOW	………………………	-2	(HCARE_SICK)

HC005 (LAST_VISIT) What was the date of {C_FNAME/YOUR CHILD}’s most recent well-child visit or check-up?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

HAS NOT HAD A VISIT	………………………………	1	(SAME_CARE)
REFUSED	………………………………	-1	(SAME_CARE)
DON’T KNOW	………………………………	-2	(SAME_CARE)

HC007 (VISIT_WT) What was {C_FNAME/YOUR CHILD}’s weight at that visit?

|___|___|

Pounds

REFUSED	………………………………	-1
DON’T KNOW	………………………………	-2

PROGRAMMER INSTRUCTION: INCLUDE A SOFT EDIT IF WEIGHT < 8 OR > 21 POUNDS

HC009 (SAME_CARE) If {C_FNAME/YOUR CHILD} is sick or if you have concerns about {his/her} health, does {he/she} go to the same place as for well-child visits?

YES	………………………………	1	(HOSPITAL)
NO	………………………………	2
HAS NOT BEEN SICK	………………………………	3	(HOSPITAL)
REFUSED	………………………………	-1
DON’T KNOW	………………………………	-2

HC011 (HCARE_SICK) What kind of place does {C_FNAME/YOUR CHILD} usually go to when {he/she} is sick, doesn’t feel well, or if you have concerns about {his/her} health?

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
HAS NOT BEEN SICK	………………………	7
REFUSED	………………………	-1
DON’T KNOW	………………………	-2

HC013 (HOSPITAL) After coming home from the hospital the first time, has your child spent at least one night in the hospital?

YES 1

NO 2 (TIME_STAMP_6)

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW 2 (TIME_STAMP_6)

HC015 (DIAGNOSIS) Did a doctor or other health care provider give your child a diagnosis?

YES 1

NO 2 (TIME_STAMP_6)

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW -2 (TIME_STAMP_6)

HC017 (DIAGNOSIS_SPECIFY) What was the diagnosis?

INTERVIEWER INSTRUCTION: ENTER ALL DIAGNOSES IN FIELD SEPARATED BY COMMAS OR AN “AND”.

________________________________

DIAGNOSES

REFUSED -1

DON’T KNOW -2

HC019 (TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Thank you for your time and for being a part of this important research study. This is the end of our interview.

LOCATION-SPECIFIC CLOSE-OUT AND SCHEDULING TEXT – include information about next contact (6 month home visit) and verification of contact information.

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.