Form 26.1 Survey

OMB #: 0925-0593

Expiration Date: 7/31/ 2013

9-Month Mother Phone Interview, Phase II

Recruitment Strategy Substudy

Event Name(s):

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

Instrument Name(s) and Versions:

9-Month Mother Phone Interview (EH, PB, HI) – V.1.0

Recruitment Groups:

Enhanced Household, Provider-Based, High Intensity

TABLE OF CONTENTS

INTERVIEW INTRODUCTION 2

participant verification 4

Child development and parenting 6

HEALTH care 10

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 10 minutes. I will ask you questions about your baby’s health and behavior. 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 9-MONTH CALL TODAY?

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

IN006 (CHILD_NUM) HOW MANY CHILDREN IN THIS HOUSEHOLD ARE ELIGIBLE FOR THE 9-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

N018 (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

8 MONTHS OR GREATER THAN 11 MONTHS

• FORMAT CHILD_DOB AS YYYYMMDD

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

Child Development and Parenting

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

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

CDP017 (SWITCH_HANDS) Move a toy or block from one hand to the other?

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

CDP018 (PICKUP) Pick up a small object like a Cheerio or raisin?

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

CDP019 (HOLD) Hold two toys or blocks at a time, one in each hand?

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

CDP021 (SOUND_3) Turn toward someone when they’re speaking?

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

CDP022 (SPEAK_1) Make sounds as though {he/she} is trying to speak?

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

CDP023 (SPEAK_2) Say mama or dada?

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

CDP024 (HEADUP) Keep head steady when sitting or held up?

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

CDP026 (ROLL_2) Roll from back to stomach?

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

CDP034 (SITUP) Sit up by {him/herself}?

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

CDP035 (STAND) Stand while holding onto something?

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

CDP036 (STAND_ALONE) Stand alone, without holding onto something?

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

CDP037 (WALK) Walk by himself, without holding onto something?

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

CDP038 (SCRIBBLE) Scribble or draw with a pencil, crayon, or marker?

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

CDP039 (FORK_SPOON) Try to use a fork or spoon when eating?

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

CDP028 (TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Health Care

HC001 (C_HEALTH) Would you say {C_FNAME/YOUR CHILD}’s health in general is poor, fair, good, or excellent?

POOR 1

FAIR 2

GOOD 3

EXCELLENT 4

REFUSED -1

DON’T KNOW -2

The next questions are about where {C_FNAME} 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	………………………………	-7	(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 < 13 OR > 26 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	(TIME_STAMP_4)
NO	………………………………	2
HAS NOT BEEN SICK	………………………………	-7	(TIME_STAMP_4)
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

HC019 (TIME_STAMP_4) 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 (12-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.