Form 27.2 Survey

Recruitment Strategy Substudy

Event Name(s):

12-Month Mother SAQ (EH, PB, HI)

Instrument Name(s) and Versions:

12-Month Mother SAQ (EH, PB, HI) – 1.0

Recruitment Groups:

Enhanced Household, Provider-Based, High Intensity

12-Month Mother SAQ (EH, PB, HI)

TABLE OF CONTENTS

SELF-ADMINISTERED QUESTIONAIRE 1

12-Month Mother SAQ (EH, PB, HI)

SELF-ADMINISTERED QUESTIONAIRE

NOTE: THE SAQS MAY BE COMPLETED IN EITHER A PAPI OR CASI MODE

INTERVIEWER INSTRUCTION: IF COMPLETED AS A PAPI, ENTER THE PARTICIPANT ID ON THE INSTRUMENT

(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IN001Thank you for agreeing to participate in the National Children’s Study. This self-administered questionnaire will take about 10 minutes to complete. There are questions about your relationships, experiences as a parent, and questions about your child’s diet.

Your answers are important to us. There are no right or wrong answers. You can skip over any question. We will keep everything that you tell us confidential.

PEB001 The first set of items are about your relationship with your spouse or partner. Please indicate the extent to which you agree or disagree with each statement.

PEB002 (SP_LISTEN) My spouse/partner listens to me when I need someone to talk to.

Strongly disagree,	………………………………………	1
Somewhat disagree	………………………………………	2
Neither agree nor disagree	………………………………………	3
Somewhat agree	………………………………………	4
Strongly agree	………………………………………	5

PEB003 (SP_FEEL) I can state my feelings without him getting defensive.

Strongly disagree,	………………………………………	1
Somewhat disagree	………………………………………	2
Neither agree nor disagree	………………………………………	3
Somewhat agree	………………………………………	4
Strongly agree	………………………………………	5

PEB004 (SP_DISTANT) I often feel distant from my spouse/partner.

Strongly disagree,	………………………………………	1
Somewhat disagree	………………………………………	2
Neither agree nor disagree	………………………………………	3
Somewhat agree	………………………………………	4
Strongly agree	………………………………………	5

PEB005 (SP_UNDERSTAND) My spouse/partner can really understand my hurts and joys.

Strongly disagree,	………………………………………	1
Somewhat disagree	………………………………………	2
Neither agree nor disagree	………………………………………	3
Somewhat agree	………………………………………	4
Strongly agree	………………………………………	5

PEB006 (SP_NEGLECT) I feel neglected at times by my spouse/partner.

Strongly disagree,	………………………………………	1
Somewhat disagree	………………………………………	2
Neither agree nor disagree	………………………………………	3
Somewhat agree	………………………………………	4
Strongly agree	………………………………………	5

PEB007 (SP_LONELY) I sometimes feel lonely when we’re together.

Strongly disagree,	………………………………………	1
Somewhat disagree	………………………………………	2
Neither agree nor disagree	………………………………………	3
Somewhat agree	………………………………………	4
Strongly agree	………………………………………	5

PEB010 The next series of questions contain statements about children. Many statements describe normal feelings and behaviors, but some describe things that can be problems. Some statements may seem too young or too old for your child. Please indicate the response that best describes your child in the LAST MONTH.

PEB011 (BEHAVE_1) Shows pleasure when he/she succeeds (for example, claps for self)

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB012 (BEHAVE_2) Gets hurt so often that you can’t take your eyes off him/her

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB013 (BEHAVE_3) Seems nervous, tense or fearful

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB014 (BEHAVE_4) Is restless and can’t sit still

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB015 (BEHAVE_5) Follows rules

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB016 (BEHAVE_6) Wakes up at night and needs help to fall asleep again

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB017 (BEHAVE_7) Cries or tantrums until he/she is exhausted

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB018 (BEHAVE_8) Is afraid of certain places, animals or things

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB019 (BEHAVE_9) Has less fun than other children

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB020 (BEHAVE_10) Looks for you (or other parent) when upset

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB021 (BEHAVE_11) Cries or hangs onto you when you try to leave

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB022 (BEHAVE_12) Worries a lot or is very serious

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB023 (BEHAVE_13) Looks right at you when you say his/her name

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB024(BEHAVE_14) Does not react when hurt

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB025 (BEHAVE_15) Is affectionate with loved ones

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB026 (BEHAVE_16) Won’t touch some objects because of how they feel

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB027 (BEHAVE_17) Has trouble falling asleep or staying asleep

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB028 (BEHAVE_18) Runs away in public places

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB029 (BEHAVE_19) Plays well with other children, not including brother/sister

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3
No contact with other children	………………………………………	4

PEB030 (BEHAVE_20) Can pay attention for a long time (not including TV)

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB031 (BEHAVE_21) Has trouble adjusting to change

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB032 (BEHAVE_22) Tries to help when someone is hurt. For example, gives a toy

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB033 (BEHAVE_23) Often gets very upset

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB034 (BEHAVE_24) Gags or chokes food

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB035 (BEHAVE_25) Imitates playful sounds when you ask him/her to

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB036 (BEHAVE_26) Refuses to eat

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB037(BEHAVE_27) Hits, shoves, kicks or bites children other than brother/sister

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3
No contact with other children	………………………………………	4

PEB038 (BEHAVE_28) Is destructive. Breaks or ruins things on purpose.

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB039 BEHAVE_29) Points to show you something far away

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB040 (BEHAVE_30) Hits, bites or kicks you or other parent

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB041 (BEHAVE_31) Hugs or feeds dolls or stuffed animals

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB042 (BEHAVE_32) Seems very unhappy, sad, depressed or withdrawn

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB043 (BEHAVE_33) Purposely tries to hurt you or other parent

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB044 (BEHAVE_34) When upset, gets very still, freezes or doesn’t move

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB047The following items are about feelings and behaviors that young children may do. Some of the questions may be a bit hard to understand, especially if you have not seen them in a child. Please do your best to answer them anyway. How do the following descriptions describe your child?

PEB048 (BEHAVIORS_1) Puts things in a special order, over and over

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB049 (BEHAVIORS_2) Repeats the same action or phrase, over and over

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB050 (BEHAVIORS_3) Repeats a particular movement, over and over (like rocking, spinning, etc.)

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB051 (BEHAVIORS_4) “Spaces out.” Is totally unaware of what’s happening around him/her

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB052 (BEHAVIORS_5) Does not make eye contact

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB053 (BEHAVIORS_6) Avoids physical contact

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB054 (BEHAVIORS_7) Eats or drinks things that are not edible, like paper or paint

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

PEB055 (BEHAVIORS_8) Hurts him/herself on purpose. For example, bangs his or her head.

Not true/Rarely	………………………………………	1
Somewhat true/Sometimes	………………………………………	2
Very true/Often	………………………………………	3

(TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

CFQ001 The next questions will ask about the milk, formula, and food your child has eaten. In the past 7 days, how often was your baby fed each item listed below?

Include feedings by everyone who feeds the baby and include snacks and night-time feedings. If your baby was fed the item once a day or more, write the number of feedings per day in the first column. If your baby was fed the item less than once a day, write the number of feedings per week in the second column. Fill in only one column for each item. If your baby was not fed the item at all during the past 7 days, write 0 in the second column.

	Number of Feedings per Day	Number of Feedings per Week
Breast milk (include breast fed and expressed or pumped breast milk)? (BREAST_DAY)/(BREAST_WEEK)	_________	_________
Formula? (FORMULA_DAY)/(FORMULA_WEEK)	_________	_________
Cow’s milk? (COW_MILK_DAY)/(COW_MILK_WEEK)	_________	_________
Other milk (soy milk, rice milk, goat milk)? (MILK_OTH_DAY)/(MILK_OTH_WEEK)	_________	_________

CFQ003 (BREAST_MILK) Please check which best describes what your baby has been fed. My baby…

	…is not drinking breast milk now, but was fed breast milk in the past	1	(BREAST_STOP)
	…is drinking breast milk now	2	(PUMPED)
	… was never fed breast milk	3	(FORMULA)

CFQ005 (BREAST_STOP) How old was your baby when you completely stopped breastfeeding and pumping or expressing breast milk?

________________

ENTER AGE

(BREAST_STOP_UNIT)

WEEKS 1

MONTHS 2

INSTRUCTION: IF BABY WAS LESS THAN ONE MONTH, ENTER AGE IN WEEKS; IF OLDER THAN ONE MONTH, ENTER AGE IN MONTHS

CFQ007 (PUMPED) Have you ever fed your baby pumped or expressed breast milk?

	Yes	1	(PUMPED_2)
	No	2	(FORMULA)

CFQ009 (PUMPED_2) In the past 7 days, about how often was your baby fed pumped or expressed breast milk? Include feedings by everyone who feeds the baby and include snacks and nighttime feedings.

	1 time per week	1
	2 to 4 times per week	2
	Nearly every day	3
	1 time per day	4
	2 to 3 times per day	5
	4 to 6 times per day	6
	More than 6 times per day	7

CFQ011 (FORMULA) How old was your baby when (he/she) was first fed formula on a daily basis?

	Less than 1 month old	1
	1 to 2 months old	2
	3 to 4 months old	3
	5 to 6 months old	4
	More than 6 months old	5

CFQ013 (FORMULA_LAST7) Has your baby had formula in the last seven days?

	Yes	1	(FORMULA_BRAND)
	No	2	(BOTTLE_TYPE)

CFQ015 (FORMULA_BRAND) What kind of infant formula was your baby fed in the past 7 days?

Infant formulas are listed alphabetically. Please put an X in the box next to each infant formula your baby was fed. (MARK ALL THAT APPLY)

	Enfamil® Premium with Triple Health Guard (FTYPE_1)			Store brand Milk based (like Member’s Mark, Kirkland, Target up & up) (FTYPE_32)
	Enfamil® Premium Next Step (FTYPE_2)			Store brand Gentle or partially broken down whey protein formula (like Member’s Mark or Target up & up)) (FTYPE_33)
	Enfamil® ProSobee® (FTYPE_3)			Store brand Soy based (like Target up & up) (FTYPE_34)
	Enfamil® RestFull (FTYPE_4)			Store brand Next step (like Target up & up) (FTYPE_35)
	Enfamil AR® (FTYPE_5)			Store brand Lacto sensitive (like Target up & up) (FTYPE_36)
	Enfamil® Gentlease® (FTYPE_6)			Store brand Prebiotic (like Target up & up) (FTYPE_37)
	Enfamil® Gentlease® Next Step (FTYPE_7)			Earth’s Best Organic Infant Formula with DHA & ARA (FTYPE_38)
	Enfamil® Enfacare (FTYPE_8)			Earth’s Best Organic Soy Infant Formula with DHA & ARA (FTYPE_39)
	Nutramigen® with Enflora LGG (FTYPE_9)			Baby’s Only Organic Dairy (FTYPE_40)
	Nutramigen® AA (FTYPE_10)			Baby’s Only Organic Soy (FTYPE_41)
	Pregestimil® (FTYPE_11)			Baby’s Only Organic Lactose Free (FTYPE_42)
	Enfamil® Premature (FTYPE_12)			Bright Beginnings milk-based (FTYPE_43)
	Enfamil® Premium Vanilla or Chocolate (FTYPE_13)			Bright Beginnings Gentle milk-based (FTYPE_44)
	Enfamil® Soy Next Step (FTYPE_14)			Bright Beginnings Organic (FTYPE_45)
	Gerber® Good Start® Gentle Plus (FTYPE_15)			Bright Beginnings milk-based 2 (FTYPE_46)
	Gerber® Good Start® Gentle Plus 2 (FTYPE_16)			Bright Beginnings NeoCare (FTYPE_47)
	Gerber® Good Start® Protect Plus (FTYPE_17)			Other—specify: (FTYPE_48) ___________________________
	Gerber® Good Start® Protect Plus 2 (FTYPE_18)			(FTYPE_OTH)
	Gerber® Good Start® Soy Plus (FTYPE_19)
	Gerber® Good Start® Soy Plus 2 (FTYPE_20)
	EleCare® (FTYPE_21)
	Similac® Advance® EarlyShield (FTYPE_22)
	Similac Isomil® Advance® (FTYPE_23)
	Similac Isomil® DF (FTYPE_24)
	Similac® Organic (FTYPE_25)
	Similac® Go & Grow (FTYPE_26)
	Similac® Go & Grow EarlyShield (FTYPE_27)
	Similac® Sensitive (FTYPE_28)
	Similac® Sensitive R.S. (FTYPE_29)
	Similac® Alimentum® (FTYPE_30)
	Similac® Neosure® (FTYPE_31)

CFQ017 (FORMULA_TYPE) Was the formula ready-to-feed, liquid concentrate, powder from a can that makes a single serving, or powder from single serving packets? (MARK ALL THAT APPLY)

	Ready-to-feed	1
	Liquid concentrate	2
	Powder from a can that makes more than one bottle	3
	Powder from single serving packets	4

If you fed your baby ready-to-feed formula ONLY, go to (OUNCES) If you fed your baby any liquid concentrate or powdered formula go to (WATER_1)

CFQ019 (WATER_1) During the past 7 days, what types of water have you and others who care for your baby used for mixing your baby’s formula? (MARK ALL THAT APPLY)

	Tap water from the cold faucet	1
	Warm tap water from the hot faucet	2
	Bottled water	3
	No water used, fed ready-to-feed formula	4

CFQ021 (WATER_2) Was the water used to mix the formula boiled?

	Yes	1
	No	2

CFQ023 (OUNCES) In the past 7 days, on the average, how many ounces of formula did your baby drink at each feeding?

____________________ Ounces

CFQ025 (BOTTLE_TYPE) In the past 7 days, about how often did your baby drink from each of the following types of bottles and cups?

	Never (1)	Sometimes (2)	Most of the time (3)	Always (4)
Plastic baby bottle with disposable bottle liner? (B_TYPE1)
Plastic baby bottle without disposable liner? (B_TYPE2)
Other plastic bottle (for example, a water bottle)? (B_TYPE3)
Glass baby bottle? (B_TYPE4)
Plastic “no spill” cup? (B_TYPE5)

CFQ027 (PACIFER) Has your baby used a pacifier in the past 7 days?

	Yes	1
	No	2

CFQ029 (COWS_MILK_1) Has your baby ever been fed cow’s milk that was not sold especially for babies? (This includes whole, lowfat, nonfat, or chocolate milk.)

	Yes	1	(COWS_MILK_2)
	No	2	(CEREAL)

CFQ031 (COWS_MILK_2) How old was your baby when he/she was first fed cow’s milk that was not sold especially for babies?

Age in months _________

CFQ033 (CEREAL) How old was your baby when he/she was first fed cereal, including baby cereal on a daily basis?

	Less than 1 month old	1
	1 to 2 months old	2
	3 to 4 months old	3
	5 to 6 months old	4
	More than 6 months old	5

CFQ035 (PUREED) How old was your baby when he/she was first fed pureed baby food on a daily basis? PLEASE INCLUDE COMMERCIAL (STORE BOUGHT) AND HOMEMADE BABY FOOD.

	Less than 1 month old	1
	1 to 2 months old	2
	3 to 4 months old	3
	5 to 6 months old	4
	More than 6 months old	5

CFQ037 (TABLE_FOOD) How old was your baby when he/she was first fed table food such as eggs, cheese, or potatoes on a daily basis?

	Less than 1 month old	1
	1 to 2 months old	2
	3 to 4 months old	3
	5 to 6 months old	4
	More than 6 months old	5

FQ039 (SUPPLEMENT) Which of the following supplements was your child given at least 3 days a week during the past 2 weeks? (MARK ALL THAT APPLY)

	Fluoride	1
	Iron	2
	Vitamin D	3
	Other vitamins or supplements: Specify ________________________________ (SUPPLEMENT_OTH)	4
	None	5

CFQ041 (HERBAL) Was your baby given any herbal or botanical preparations or any kind of tea or home remedy in the past 7 days? Do not count preparations put on the baby’s skin or anything the baby may have gotten from breast milk after you took an herbal or botanical preparation.

	Yes	1
	No	2

(TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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

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

12-Month Mother SAQ (EH, PB, HI) Version 1.1 0