Form 16.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 07/31/2013

Pregnancy Visit 2 Interview Instrument, Phase II

ASSUME PREGNANCY VISIT 1 WAS

ADMINISTERED UNLESS NOTED

Event Name(s):

Pregnancy Visit 2 Instrument (EH, PB, HI)

Instrument Name(s) and Versions:

Pregnancy Visit 2 Instrument (EH, PB, HI) – 2.0

Recruitment Groups:

Enhanced Household, Provider-Based, and High Intensity

Pregnancy Visit 2 Interview Instrument (EH, PB, HI)

TABLE OF CONTENTS

CAPI 1

INTERVIEW INTRODUCTION 1

CURRENT PREGNANCY INFORMATION 4

HOUSING CHARACTERISTICS 15

EMPLOYMENT 24

SOCIAL SUPPORT 25

HEALTH INSURANCE 27

TRACING QUESTIONS 29

Pregnancy Visit 2 Interview Instrument (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 PARTICIPANT’S NAME]?

YES 1 (DOB_CONFIRM)

NO 2

REFUSED -1

DON’T KNOW -2

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

_________________________ _________________________

FIRST NAME LAST NAME

(R_FNAME) (R_LNAME)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTIONS:

• IF PARTICIPANT 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 PARTICIPANTS.

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

YES 1 (AGE_ELIG)

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• PRELOAD PARTICIPANT’S DOB IF COLLECTED PREVIOUSLY

• IF RESPONSE = YES, SET PERSON_DOB TO KNOWN VALUE

INTERVIEWER INSTRUCTIONS:

IF PARTICIPANT 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 PARTICIPANT 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 TH AN 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

PARTICIPANT IS AGE-ELIGIBLE 1

PARTICIPANT IS YOUNGER THAN AGE OF MAJORITY 2 (END)

PARTICIPANT IS OVER AGE 49 3

AGE ELIGIBILITY IS UNKNOWN 4

• IF VALUE IS -1 OR -2, 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 PARTICIPANT HAS REPORTED BEING PREGNANT WITH MULTIPLES FILL IN “BABIES’ AS APPROPRIATE THROUGHOUT INSTRUMENT

CP001. First, I’d like to update some information about your current pregnancy.

CPI001A/(PREGNANT). The first questions ask about how your pregnancy is progressing. First, are you still pregnant?

YES 1 (DUE_DATE)

NO 2

REFUSED -1 (END)

DON’T KNOW -2 (END)

(TIME_STAMP_3) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

CPI001B. 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 PARTICIPANT AND GO TO LOSS_INFO.

• OTHERWISE GO TO END_LOSS.

CPI001C/(LOSS_INFO). INTERVIEWER ANSWERED QUESTION: DID PARTICIPANT REQUEST ADDITIONAL INFORMATION ON COPING WITH PREGNANCY LOSS?

YES 1 (eND_LOSS)

NO 2 (eND_LOSS)

CPI002/(DUE_DATE). What is your current due date?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

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

CPI004A/(DATE_KNOWN). INTERVIEWER COMPLETED QUESTION

DID PARTICIPANT GIVE DATE?

PARTICIPANT GAVE COMPLETE DATE 1

PARTICIPANT GAVE PARTIAL DATE 2

REFUSED - 1

DON’T KNOW - 2

CPI007/(BPLAN_CHANGE). Has the place where you plan to deliver your [baby/babies] changed since we last spoke with you?

YES 1

NO 2

REFUSED -1 (DATE_VISIT)

DON’T KNOW -2

CPI008/(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 (USE_PR_LOG)

Some other place? 4

REFUSED -1 (USE_PR_LOG)

DON’T KNOW -2 (USE_PR_LOG)

CPI009/(BIRTH_ADDR). 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

CPI010 (USE_PR_LOG). 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 (NUM_PROV_LOG)

NO 2

REFUSED -1 (CPI017)

DON’T KNOW -2 (CPI017)

CPI011/(REASON_NO_PR_LOG). Is that because…

You haven’t had a medical visit since our last interview, 1 (CPI017)

You’ve misplaced the log, or 2 (CPI013)

You’ve forgotten to bring it to your medical visits? 3 (CPI014)

The log was too much trouble to complete, or 4 (CPI014)

The log was too difficult to understand? 5 (CPI017)

OTHER (SPECIFY): 6

REFUSED -1 (CPI014)

DON’T KNOW -2 (CPI014)

CPI012/(REASON_NO_PR_LOG_OTH). OTHER: SPECIFY

_____________________________________ (CPI017)

CPI013. We’ll get another Pregnancy Health Care Log in the mail to you today.

CPI014. 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. (CPI017)

CPI015/(NUM_PROV_PR_LOG). How many health care providers have you seen since using this Pregnancy Health Care Log?

|___|___|

NUMBER OF PROVIDERS

REFUSED -1

DON’T KNOW -2

CPI016/(NUM_PROV_REC). Of those providers that you have seen, how many providers have you recorded their contact information such as address or phone number?

|___|___|

NUMBER OF CONTACTS

REFUSED -1

DON’T KNOW -2

CPI017. 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.

PROGRAMMER INSTRUCTION:

• DISPLAY TEXT IN BRACKETS IN CPI017 IF USE_PR_LOG=1.

CPI018/(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 -7 (CPI020)

REFUSED -1 (CPI020)

DON’T KNOW -2 (CPI020)

PROGRAMMER INSTRUCTION:

• DISPLAY CPI019 IF USE_PR_LOG=1.

INTERVIEWER INSTRUCTION:

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

CPI019. 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.

CPI020. {At this visit or at/{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, DISPLAY “At this visit or At”. OTHERWISE DISPLAY ‘”At”

INTERVIEWER INSTRUCTIONS:

• RE-READ INTRODUCTORY STATEMENT ({At this visit or at/{At} any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?) AS NEEDED

CPI020A/(DIABETES_1). Diabetes?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020B/(HIGHBP_PREG). High blood pressure?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020C/(URINE). Protein in your urine?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020D/(PREECLAMP). Preeclampsia or toxemia?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020E/(EARLY_LABOR). Early or premature labor?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020F/(ANEMIA). Anemia or low blood count?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020G/(NAUSEA). Severe nausea or vomiting (hyperemesis)?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020G/(KIDNEY). Bladder or kidney Infection?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020H/(RH_DISEASE). Rh disease or isoimmunization?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020I/(GROUP_B). Infection with a bacteria called Group B strep?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020J/(HERPES). Infection with a Herpes virus?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPI020K/(VAGINOSIS). Infection of the vagina with bacteria (Bacterial vaginosis?)

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CPIO20L/(OTH_CONDITION). Any other serious condition?

YES 1

NO 2 (TIME_STAMP_4)

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

CPI020M/(CONDITION_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_4) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

CPI021/(HOSPITAL). Since you’ve been pregnant, have you spent at least one night in the hospital?

YES 1

NO 2 (TIME_STAMP_5)

REFUSED -1 (TIME_STAMP_5)

DON’T KNOW -2 (TIME_STAMP_5)

CPI022/(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

CPI023/(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

CPI024/(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)

CPI025/(DIAGNOSE_2). What was the diagnosis?

INTERVIEWER INSTRUCTION:

• PROBE FOR MULTIPLE RESPONSES.

SELECT ALL THAT APPLY.

DEHYDRATION 1

PRETERM LABOR 2

HYPEREMESIS 3

PREECLAMPSIA 4

RUPTURE OF MEMBRANES 5

KIDNEY DISORDER 6

OTHER -5

REFUSED -1 (CPI027)

DON’T KNOW -2 (CPI027)

PROGRAMMER INSTRUCTIONS:

• IF DIAGNOSE_2 CODED WITH ANY COMBINATION OF VALUES 1 – 6, THEN GO TO CPI027.

• IF DIAGNOSE_2 CODED -5, OR ANY COMBINATION OF VALUES 1 – 6 AND -5, GO TO DIAGNOSIS_OTH. IF DIAGNOSE_2 CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO CPI027.

CPI026/(DIAGNOSIS_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• DISPLAY CPI027 IF USE_PR_LOG=1.

CPI027. 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

HC001. Now I’d like to find out more about your home and the area in which you live.

HC001A/(RECENT_MOVE). Have you moved or changed your housing situation since we last spoke with you?

YES 1

NO 2 (TIME_STAMP_6)

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW -2

HC002/(OWN_HOME). Is your home…

Owned or being bought by you or someone in your household 1 (AGE_HOME)

Rented by you or someone in your household, or 2 (AGE_HOME)

Occupied without payment of rent? 3 (AGE_HOME)

SOME OTHER ARRANGEMENT -5

REFUSED -1 (AGE_HOME)

DON’T KNOW -2 (AGE_HOME)

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?

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT

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?

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT

ELECTRIC 1 (HEAT2)

GAS – PROPANE OR LP 2 (HEAT2)

OIL 3 (HEAT2)

WOOD 4 (HEAT2)

KEROSENE OR DIESEL 5 (HEAT2)

COAL OR COKE 6 (HEAT2)

SOLAR ENERGY 7 (HEAT2)

HEAT PUMP _ 8 (HEAT2)

NO HEATING SOURCE 9(COOLING)

OTHER -5

REFUSED -1 (COOLING)

DON’T KNOW -2(COOLING)

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?

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT

• 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 (COOLING)

OTHER -5

REFUSED -1 (COOLING)

DON’T KNOW -2 (COOLING)

PROGRAMMER INSTRUCTIONS:

• IF HEAT2 CODED WITH ANY COMBINATION OF VALUES 1 – 8, THEN GO TO COOLING.

• IF HEAT2 CODED 9, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO COOLING.

• IF HEAT2 CODED -5, OR ANY COMBINATION OF VALUES 1 – 8 AND -5, GO TO HEAT2_OTH.

• IF HEAT2 CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO COOLING.

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 (TIME_STAMP_6)

Some other cooling system -5

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW -2 (TIME_STAMP_6)

PROGRAMMER INSTRUCTIONS:

• IF COOL CODED WITH ANY COMBINATION OF VALUES 1 - 3, THEN GO TO TIME_STAMP_6.

• IF COOL CODED 4, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_6.

• IF HEAT2 CODED -5, OR ANY COMBINATION OF VALUES 1 – 3 AND -5, GO TO COOL_OTH.

• IF COOL CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_6.

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 (WATER_COOK)

Filtered tap water, 2 (WATER_COOK)

Bottled water, or 3 (WATER_COOK)

Some other source? -5

REFUSED -1 (WATER_COOK)

DON’T KNOW -2 (WATER_COOK)

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 (TIME_STAMP_7)

Filtered tap water, 2 (TIME_STAMP_7)

Bottled water, or 3 (TIME_STAMP_7)

Some other source? -5

REFUSED -1 (TIME_STAMP_7)

DON’T KNOW -2 (TIME_STAMP_7)

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

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

PARTICIPANT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5

REFUSED -1 (TIME_STAMP_8)

DON’T KNOW -2 (TIME_STAMP_8)

PROGRAMMER INSTRUCTIONS:

• IF ROOM_MOLD CODED WITH ANY COMBINATION OF VALUES 1 – 7, THEN GO TO TIME_STAMP_8.

• IF ROOM_MOLD CODED -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO ROOM_MOLD_OTH.

• IF ROOM_MOLD CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_8.

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 (PDECORATE2)

REFUSED -1 (PDECORATE2)

DON’T KNOW -2 (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

PARTICIPANT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5

REFUSED -1(PDECORATE2)

DON’T KNOW -2(PDECORATE2)

PROGRAMMER INSTRUCTIONS:

• IF PRENOVATE2_ROOM CODED WITH ANY COMBINATION OF VALUES 1 – 7, THEN GO TO PDECORATE2.

• IF PRENOVATE2_ROOM CODED -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO PRENOVATE2_ROOM_OTH.

• IF PRENOVATE2_ROOM CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO PDECORATE2.

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

PARTICIPANT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

PROGRAMMER INSTRUCTIONS:

• IF PDECORATE2_ROOM CODED WITH ANY COMBINATION OF VALUES 1 – 7, THEN GO TO TIME_STAMP_9.

• IF PDECORATE2_ROOM CODED -5, OR ANY COMBINATION OF VALUES 1 – 7 AND -5, GO TO PDECORATE2_ROOM_OTH.

• IF PDECORATE2_ROOM CODED -1 OR -2, DO NOT ALLOW SELECTION OF ADDITIONAL RESPONSES AND GO TO TIME_STAMP_9.

HC026A/(PDECORATE2_ROOM_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

EMPLOYMENT

(TIME_STAMP_9) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

EM001. Now, I’d like to ask some questions about your current employment status.

EM001A. 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.

EM002/(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)

EM002A/(HOURS). Approximately how many hours each week are you working?

|___|___|___|

NUMBER OF HOURS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• DISPLAYA SOFT EDIT IF RESPONSE > 60

EM002B/(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

SS001. 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:

• SHOW RESPONSE OPTIONS ON CARD TO PARTICIPANT

SS001A/(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

HI001. 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.

INTERVIEWER INSTRUCTIONS:

• RE-READ INTRODUCTORY STATEMENT (Do you currently have…) AS NEEDED

hi003/(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

HI004/(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

HI005/(INS_TRICARE). TRICARE, VA, or other military health care?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI006/(INS_IHS). Indian Health Service?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI007/(INS_MEDICARE). Medicare, for people with certain disabilities?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HI008/(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

TR001. 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). {So that I make sure that I have your latest information, do you have an email address}/{Do you have an email address}?

PROGRAMMER INSTRUCTION:

• IF COMM_EMAIL=1, DISPLAY, “Do you have an email address?”

• IF COMM_EMAIL = 3,-1,OR -2 DISPLAY “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 ADDRESS 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). {So that I make sure that I have your latest information, do you have a personal cell phone}/{Do you have a personal cell phone}?

PROGRAMMER INSTRUCTION:

• IF COMM_CELL =1, DISPLAY, “Do you have a personal cell phone?”

• IF COMM_CELL = 3, -1, -2, DISPLAY “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

PARTICIPANT HAS NO CELL PHONE 1

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_13) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

TR110/(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 (END)

DON’T REMEMBER 3

REFUSED -1

DON’T KNOW -2

TR111/(CONTACT_1).

PROGRAMMER INSTRUCTIONS:

• IF COMM_CONTACT =1 DISPLAY “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, DISPLAY “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 (END)

REFUSED -1 (END)

DON’T KNOW -2 (END)

TR112/(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 PARTICIPANT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TR113/(CONTACT_RELATE_1). What is his/her relationship to you?

MOTHER/FATHER 1 (CONTACT_ADDR_1)

BROTHER/SISTER 2 (CONTACT_ADDR_1)

AUNT/UNCLE 3 (CONTACT_ADDR_1)

GRANDPARENT 4 (CONTACT_ADDR_1)

NEIGHBOR 5 (CONTACT_ADDR_1)

FRIEND 6 (CONTACT_ADDR_1)

OTHER -5

REFUSED -1 (CONTACT_ADDR_1)

DON’T KNOW -2 (CONTACT_ADDR_1)

TR011/(CONTACT_RELATE1_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

TR115/(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

TR116/(CONTACT_PHONE_1). What is his/her telephone number?

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

PHONE NUMBER

REFUSED -1

DON’T KNOW -2

CONTACT HAS NO TELEPHONE -7

INTERVIEWER INSTRUCTION:

• IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

TR117/(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 (END)

REFUSED -1 (END)

DON’T KNOW -2 (END)

INTERVIEWER INSTRUCTION:

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

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TR118/(CONTACT_RELATE_2). What is his/her relationship to you?

MOTHER/FATHER 1 (CONTACT_ADDR_2)

BROTHER/SISTER 2 (CONTACT_ADDR_2)

AUNT/UNCLE 3 (CONTACT_ADDR_2)

GRANDPARENT 4 (CONTACT_ADDR_2)

NEIGHBOR 5 (CONTACT_ADDR_2)

FRIEND 6 (CONTACT_ADDR_2)

OTHER -5

REFUSED -1 (CONTACT_ADDR_2)

DON’T KNOW -2 (CONTACT_ADDR_2)

TR119/(CONTACT_RELATE2_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

TR120/(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

TR121/(CONTACT_PHONE_2). What is his/her telephone number?

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

PHONE NUMBER

CONTACT HAS NO TELEPHONE -7

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

TR122/(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 condolences. Thank you for your time.

PROGRAMMER INSTRUCTION:

• IF LOSS_INFO = 1, DISPLAY TEXT IN BRACKETS {We’ll send the information packet you requested as soon as possible.}

INTERVIEWER INSTRUCTION:

• END INTERVIEW. DO NOT ADMINISTER SAQs.

TR123/(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:

• IF AGE_ELIG=2 (MINOR), DO NOT OFFER SAQS. IF PREGNANT=-1 OR -2, DO NOT OFFER SAQS.

• FOR ALL OTHERS, EXPLAIN SAQS AND RETURN PROCESS

(TIME_STAMP_14) 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.