49.2 Survey

Recruitment Strategy Substudy

Event Name(s):

Biospecimen Blood Instrument (EH, PB, HI) – 1.0

(Pre-Pregnancy Visit, Pregnancy Visit 1, Pregnancy Visit 2)

Instrument Name(s) and Versions:

Biospecimen Blood Instrument (EH, PB, HI) – 1.0

(Pre-Pregnancy Visit, Pregnancy Visit 1, Pregnancy Visit 2)

Recruitment Groups:

Enhanced Household, Provider-Based, and High Intensity

Biospecimen Blood Instrument (EH, PB, HI)

(Pre-Pregnancy Visit, Pregnancy Visit 1, Pregnancy Visit 2)

TABLE OF CONTENTS

CAPI 1

BIOSPECIMEN BLOOD COLLECTION 1

Biospecimen Blood Instrument (EH, PB, HI)

(Pre-Pregnancy Visit, Pregnancy Visit 1, Pregnancy Visit 2)

CAPI

Biospecimen BLOOD COLLECTION

(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

BL0100 (BLIntro). I will now collect a blood sample. I will need to ask you some questions before I collect your blood sample.

CONTINUE 01

REFUSED 02 (BL2060)

BL0200 (BLHemophilia). Do you have hemophilia or any bleeding disorder?

YES 01 (BL1800)

NO 02

REFUSED 9-97 (BL2050)

DON’T KNOW 9-98 (BL2050)

DATA COLLECTOR INSTRUCTIONS:

RESPONSE DETERMINES ELIGIBILITY OF STUDY PARTICIPANT FOR BLOOD DRAW.

BL0300 (BLBloodThinner). Do you take any blood thinning medication, such as Coumadin or warfarin?

YES 01 (BL1900)

NO 02

REFUSED 9-97 (BL2050)

DON’T KNOW 9-98 (BL2050)

DATA COLLECTOR INSTRUCTIONS:

RESPONSE DETERMINES ELIGIBILITY OF STUDY PARTICIPANT FOR BLOOD DRAW.

BL0400 (BLChemo). Have you had cancer chemotherapy within the past 4 weeks?

YES 01 (BL2000)

NO 02

REFUSED 9-97 (BL2050)

DON’T KNOW 9-98 (BL2050)

DATA COLLECTOR INSTRUCTIONS:

RESPONSE DETERMINES ELIGIBILITY OF STUDY PARTICIPANT FOR BLOOD DRAW.

BL0500 (BLBloodDraw). Have you had any problems with taking blood in the past?

YES 01 (BL0700)

NO 02

REFUSED 9-97 (BL0700)

DON’T KNOW 9-98 (BL0700)

BL0600 (BLCmpBloodDraw). What problems did you have with taking blood in the past?

FAINTING 01

LIGHT-HEADEDNESS 02

HEMATOMA 03

BRUISING 04

OTHER

SPECIFY______________________________ 96

REFUSED 9-97 (BL0700)

DON’T KNOW 9-98 (BL0700)

DATA COLLECTOR INSTRUCTIONS:

CHECK ALL THAT APPLY.

BL0700 (BL0700-CmpBlLastTime). When was the last time you had anything to eat or drink other than water?

BL0700a (BL0700a-BlLastTimeEat) |___|___|:|___|___|

(BL0700c-BlDateLastTimeEat) ) |___|___|/___|___|/___|___|___|___| MM/DD/YYYY

(BL0700b-BlAmPmLastTimeEat)

AM 01 (BL0700)

PM 02

REFUSED 9-97 (BL0700)

DON’T KNOW 9-98 (BL0700)

DATA COLLECTOR INSTRUCTION:

• {PARTICIPANT REPORTED {UrLastTimeEat} {UrAmPmLastTimeEat} {UrDateLastTimeEat} AT URINE COLLECTION. VERIFY AND} ENTER TIME AS HH:MM AND AM OR PM.

• ENTER TIME AS HH:MM AND AM OR PM.

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

BL0900 (BLCoffeeTea). Have you had coffee or tea with sweetener or milk in the last 8 hours?

YES 01

NO 02

REFUSED 9-97

DON’T KNOW 9-98

BL1000 (BLAlcohol). Have you had alcohol such as beer, wine, or liquor in the last 8 hours?

YES 01

NO 02

REFUSED 9-97

DON’T KNOW 9-98

BL1100 (BLCoughCold). Have you chewed gum, used breath mints, lozenges or cough drops, or other cough or cold remedies in the last 8 hours?

YES 01

NO 02

REFUSED 9-97

DON’T KNOW 9-98

BL1200 (BLLaxative). Have you used antacid, laxatives, or anti-diarrheal medication in the last 8 hours?

YES 01

NO 02

REFUSED 9-97

DON’T KNOW 9-98

BL1300 (BLVitamin). Have you taken a dietary supplement such as vitamins or minerals in the last 8 hours?

YES 01

NO 02

REFUSED 9-97

DON’T KNOW 9-98

BL1400 (BLDiabetes). Are you diabetic? This includes gestational diabetes?

YES 01

NO 02

REFUSED 9-97

DON’T KNOW 9-98

BL1500 (BLInsulin). Have you taken any insulin in the last 8 hours?

YES 01

NO 02

REFUSED 9-97

DON’T KNOW 9-98

BL1600 (CmpBLKit). Thank you for answering my questions. I am now going to prepare to draw your blood

REFUSED 9-97 (End of Module)

(BL1800) STATEMENT: Because you have hemophilia, we will not be able to draw your blood for this study. GO TO END OF MODULE.

(BL1900) STATEMENT: Because you are taking a blood thinning medication, we will not be able to draw your blood at this time. GO TO END OF MODULE.

(BL2000) STATEMENT: Because you’ve had chemotherapy recently, we will not be able to draw your blood at this time. GO TO END OF MODULE.

(BL2050) STATEMENT: Because you do not know or declined to answer questions about your hemophilia or chemotherapy status and the use of blood thinners we will not be able to draw your blood. GO TO END OF MODULE.

Biospecimen Blood Instrument (EH, PB, HI) Version 1.0 0