Form 15.1 Survey

OMB #: 0925-0593

Expiration Date: 07/31/2013

Pregnancy Visit 1 Instrument, Phase II

Recruitment Strategy Substudy: Phase II

Event Name(s):

Pregnancy Visit 1 Instrument (EH, PB, HI)

Pregnancy Visit 1 Instrument (EH, PB, HI) – SAQ

Instrument Name(s) and Versions:

Pregnancy Visit 1 Instrument (EH, PB, HI) – 2.0

Pregnancy Visit 1 Instrument (EH, PB, HI) – SAQ – 2.0

Recruitment Groups:

Enhanced Household, Provider-Based, and High Intensity

Pregnancy Visit 1 Instrument and SAQ (EH, PB, HI)

TABLE OF CONTENTS

CAPI 1

INTERVIEW INTRODUCTION 1

CURRENT PREGNANCY INFORMATION 3

MEDICAL HISTORY 10

HEALTH INSURANCE 12

HOUSING CHARACTERISTICS 14

PETS 20

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS 21

COMMUTING 22

FAMILY INCOME 25

TRACING QUESTIONS 27

PREGNANCY CARE LOG INSTRODUCTION 35

Pregnancy Visit 1 Instrument and SAQ (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 30 minutes to complete. Your answers are important to us. There are no right or wrong answers. During this interview, we will ask you questions about yourself, your health and pregnancy, your household 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 RESPONDENT NAME]___________?

YES 1 (DOB_CONFIRM)

NO 2 (R_FNAME)(R_LNAME).

REFUSED…………………………………………….. -1 (R_FNAME)(R_LNAME).

DON’T KNOW…………………………………………. -2 (R_FNAME)(R_LNAME).

PROGRAMMER INSTRUCTION; INSERT RESPONDENT’S NAME IF KNOWN

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

_________________________ _________________________

FIRST NAME LAST NAME

(R_FNAME) (R_LNAME)

REFUSED -1 (IN003)/(DOB_CONFIRM)

DON’T KNOW -2 (IN003)/(DOB_CONFIRM)

INTERVIEWER INSTRUCTIONS:

• IF RESPONDENT 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 RESPONDENTS.

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

YES 1 (AGE_ELIG)

NO 2 (IN003A)/(PERSON_DOB).

REFUSED -1 (IN003A)/(PERSON_DOB)

DON’T KNOW -2 (IN003A)/(PERSON_DOB).

PROGRAMMER INSTRUCTION;

• PRELOAD RESPONDENT’S DOB IF KNOWN

• IF RESPONSE = YES, SET PERSON_DOB TO KNOWN VALUE

INTERVIEWER INSTRUCTIONS:

• IF RESPONDENT 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 (AGE_ELIG)

DON’T KNOW -2 (AGE_ELIG)

INTERVIEWER INSTRUCTION:

• IF RESPONDENT 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 THAN 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

RESPONDENT IS AGE-ELIGIBLE 1 (TIME_STAMP_2)

RESPONDENT IS YOUNGER THAN AGE OF MAJORITY 2 (END)

RESPONDENT IS OVER AGE 49 3 (TIME_STAMP_2)

AGE ELIGIBILITY IS UNKNOWN 4 (TIME_STAMP_2)

IF VALUE IS ‘REFUSED’ OR ‘DON’T KNOW’ 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

CP000. We’ll begin by asking some questions about you, your health, and your health history. First, I’ll ask about your current pregnancy.

CP001/(PREGNANT). The first questions ask about how your pregnancy is progressing. Are you still pregnant?

YES 1 (TIME_STAMP_3)

NO 2 (TIME_STAMP_3)

REFUSED -1 (TR010)/(END)

DON’T KNOW -2 (TR010)/(END)

(TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

[IF (PREGNANT) = 1 GO TO (DUE_DATE)]

[IF (PREGNANT) = 2 GO TO CP001A]

CP001A. 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 RESPONDENT AND GO TO CP001C/(LOSS_INFO).

• OTHERWISE GO TO TR009/(END_LOSS).

CP001C/(LOSS_INFO).INTERVIEWER ANSWERED QUESTION: DID RESPONDENT REQUEST ADDITIONAL INFORMATION ON COPING WITH PREGNANCY LOSS?

YES 1 (TR009)/(eND_LOSS).

NO 2 (TR009)/(eND_LOSS).

CP002/(DUE_DATE). What is your current due date?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

IF VALID RESPONSE PROVIDED (KNOW_DATE)

REFUSED -1 (DATE_PERIOD).

DON’T KNOW -2 (DATE_PERIOD).

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 (KNOW_DATE)

  • IF NO VALID DATE IS GIVEN  GO TO CP004 (DATE_PERIOD)

CP003/(KNOW_DATE). How did you find out your due date?

FIGURED IT OUT MYSELF 1 (DATE_PERIOD)

HAD AN ULTRASOUND TO FIGURE IT OUT 2 (DATE_PERIOD)

DOCTOR OR OTHER PROVIDER TOLD ME

WITHOUT AN ULTRASOUND 3 (DATE_PERIOD)

REFUSED -1 (DATE_PERIOD)

DON’T KNOW -2 (DATE_PERIOD)

CP004/(DATE_PERIOD). What was the first day of your last menstrual period?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

IF RESPONSE PROVIDED (KNEW_DATE)

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

INTERVIEWER INSTRUCTION:

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

• CODE DAY AS “15” IF RESPONDENT IS UNSURE/UNABLE TO ESTIMATE DAY.

• IF RESPONSE WAS DETERMINED TO BE INVALID, ASK QUESTION AGAIN AND PROBE FOR VALID RESPONSE

PROGRAMMER INSTRUCTIONS:

• CHECK REPORTED MENSTRUAL DATE AGAINST CURRENT DATE; DISPLAY APPROPRIATE MESSAGE:

  • IF DATE IS MORE THAN 10 MONTHS BEFORE CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT IS MORE THAN 10 MONTHS BEFORE TODAY. CONFIRM DATE. IF DATE IS CORRECT, ENTER ‘DON’T KNOW’.”

  • IF DATE IS AFTER CURRENT DATE, DISPLAY INTERVIEWER INSTRUCTION: “YOU HAVE ENTERED A DATE THAT HAS NOT OCCURRED YET. RE-ENTER DATE.”

  • IF VALID DATE WAS PROVIDED, CALCULATE DUE DATE FROM THE FIRST DATE OF LAST MENSTRUAL PERIOD AND SET (DUE_DATE) (YYYYMMDD) = (DATE_PERIOD) + 280 DAYS; GO TO (KNEW_DATE)

CP004a/(KNEW_DATE). DID RESPONDENT GIVE DATE?

RESPONDENT GAVE COMPLETE DATE 1

INTERVIEWER ENTERED 15 FOR DAY 2

(TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

CP005/(HOME_TEST). Did you use a home pregnancy test to help find out you were pregnant?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CP006/(MULTIPLE_GESTATION). Are you pregnant with a single baby (singleton), twins, or triplets or other multiple births?

SINGLETON 1

TWINS 2

TRIPLETS OR HIGHER 3

REFUSED -1

DON’T KNOW -2

CP008/(BIRTH_PLAN). Where do you plan to deliver your (baby/babies)?

In a hospital, 1

A birthing center, 2

At home, or 3 (CP010) /(PN_VITAMIN)

Some other place? 4

REFUSED -1 (CP010) /(PN_VITAMIN)

DON’T KNOW -2 (CP010) /(PN_VITAMIN)

CP009. 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

CP010/(PN_VITAMIN). In the month before you became pregnant, did you regularly take multivitamins, prenatal vitamins, folate, or folic acid?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

CP012./(PREG_VITAMIN) Since you’ve become pregnant, have you regularly taken multivitamins, prenatal vitamins, folate, or folic acid?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DV003 (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 1

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: ENTER A TWO DIGIT MONTH, TWO DIGIT DAY, AND A FOUR DIGIT YEAR

DV013./ [At this visit or] 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, FILL TEXT WITH “AT THIS VISIT OR” OTHERWISE BEGIN QUESITON TEXT WITH ‘AT ANY TIME DURING…”

INTERVIEWER INSTRUCTIONS: RE-READ INTRODUCTORY STATEMENT AS NEEDED

(DIABETES_1) Diabetes?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

[At this visit or] at any time during your pregnancy, did the doctor or other health care provider tell you that you have any of the following conditions?

(HIGHBP_PREG) High blood pressure?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(URINE) Protein in your urine?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(PREECLAMP) Preeclampsia or toxemia?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(EARLY_LABOR) Early or premature labor?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(ANEMIA) Anemia or low blood count?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(NAUSEA) Severe nausea or vomiting (hyperemesis)?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(KIDNEY) Bladder or kidney Infection

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(RH_DISEASE) Rh disease or isoimmunization?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(GROUP_B) Infection with bacteria called Group B strep?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(HERPES) Infection with a Herpes virus?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(VAGINOSIS) Infection of the vagina with bacteria (bacterial vaginosis?)

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(OTH_CONDITION) Any other serious condition?

YES 1 (CONDITION_OTH)

NO 2

REFUSED -1

DON’T KNOW -2

DV014. (CONDITION_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

MEDICAL HISTORY

(TIME_STAMP_5) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

MC001. This next question is about your health when you are not pregnant.

MC002./(HEALTH). Would you say your health in general is . . .

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

REFUSED -1

DON’T KNOW -2

MC103./(HEIGHT_FT) ./(HT_INCH). How tall are you without shoes?

|___| |___|___|

Feet Inches

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• INCLUDE A SOFT EDIT IF HEIGHT_FT > 7 OR < 4

• IF HEIGHT_FT IS PROVIDED INCLUDE A SOFT EDIT IF HT_INCH > 12

• IF HEIGHT_FT IS NOT PROVIDED INCLUDE A SOFT EDIT IF HT_INCH > 84 OR < 48

MC104./(WEIGHT). What was your weight just before you became pregnant?

|___|___|___|

Pounds

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: INCLUDE A SOFT EDIT IF WEIGHT < 90 OR > 400

MC110. The next questions are about medical conditions or health problems you might have now or may have had in the past.

MC003/(ASTHMA). Have you ever been told by a doctor or other health care provider that you had asthma?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC004./(HIGHBP_NOTPREG). (Have you ever been told by a doctor or other health care provider that you had)

Hypertension or high blood pressure when you’re not pregnant?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC005/(DIABETES_NOTPREG).. (Have you ever been told by a doctor or other health care provider that you had)

High blood sugar or Diabetes when you’re not pregnant?

YES 1 (DIABETES_2)

NO 2 (THYROID_1)

REFUSED -1 (THYROID_1)

DON’T KNOW -2 (THYROID_1)

MC005a/(DIABETES_2).. Have you taken any medicine or received other medical treatment for diabetes in the past 12 months?

YES 1 (DIABETES_3)

NO 2 (DIABETES_3)

REFUSED -1 (DIABETES_3)

DON’T KNOW -2 (DIABETES_3)

MC005b/(DIABETES_3) Have you ever taken insulin?

YES 1 (THYROID_1)

NO 2 (THYROID_1)

REFUSED -1 (THYROID_1)

DON’T KNOW -2 (THYROID_1)

MC006/(THYROID_1).. (Have you ever been told by a doctor or other health care provider that you had) Hypothyroidism, that is, an under active thyroid?

YES 1 (THYROID_2)

NO 2

REFUSED -1

DON’T KNOW -2

MC006a/(THYROID_2).. Have you taken any medicine or received other medical treatment for a thyroid problem in the past 12 months?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MC012A. This next question is about where you go for routine health care.

MC012/(HLTH_CARE). What kind of place do you usually go to when you need routine or preventive care, such as a physical examination or check-up?

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 PREVENTIVE CARE ANYWHERE 7

REFUSED -1

DON'T KNOW -2

HEALTH INSURANCE

(TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HI000. Now I’m going to switch to another subject and ask about health insurance.

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_7)

REFUSED -1 (TIME_STAMP_7)

DON’T KNOW -2 (TIME_STAMP_7)

HI002 Now I’ll read a list of different types of insurance. Please tell me which types you currently have. Do you currently have…

INTERVIEWER INSTRUCTIONS: RE-READ INTRODUCTORY STATEMENT AS NEEDED

(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

(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

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

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_IHS) Indian Health Service?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_MEDICARE) Medicare, for people with certain disabilities?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

(INS_OTH) Any other type of health insurance or health coverage plan?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HOUSING CHARACTERISTICS

(TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC. Now I’m going to ask about the dust sampling you completed, and the air sampling that will be completed in your home.

HC When was the last time you had vacuumed your family/living room prior to completing the dust sample?

______/______/____________ MM/DD/YYYY

REFUSED -1

DON’T KNOW -2

DATA COLLECTOR INSTRUCTIONS:

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

HC What did you think of the dust collection?

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC Was the length of time it took to collect the sample acceptable?

YES……………………………………………………………….1

NO 2

REFUSED -1

DON’T KNOW -2

HC Do you have any other comments about the dust collection?

YES……………………………………………………………….1

NO 2

REFUSED -1

DON’T KNOW -2

HCA.

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: IF STUDY CENTER IS NOT PARTICIPATING IN LOI3-ENV-01-D, THEN SKIP TO HC000.

HC What do you think about the air sampler that we are leaving in your home?

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC Is the size of the device acceptable?

YES……………………………………………………………….1

NO 2

REFUSED -1

DON’T KNOW -2

HC Is the location of the device acceptable?

YES……………………………………………………………….1

NO 2

REFUSED -1

DON’T KNOW -2

HC Do you have any concerns about the device being left in your home for the next 30 days?

YES……………………………………………………………….1

NO 2

REFUSED -1

DON’T KNOW -2

HC000. Now I’d like to find out more about your home and the area in which you live.

PROGRAMMER INSTRUCTIONS: [IF (OWN_HOME) WAS ASKED DURING PREGNANCY SCREENER OR PRE-PREGANCY VISIT, THEN ASK HC001 (RECENT_MOVE); ELSE SKIP TO (OWN_HOME)]

HC001/(RECENT_MOVE). Have you moved or changed your housing situation since we contacted you last?

YES 1 (HC002)/(OWN_HOME)

NO 2 (HC004)/(AGE_HOME)

REFUSED -1 (HC004)/(AGE_HOME)

DON’T KNOW -2 (HC004)/(AGE_HOME)

HC002/(OWN_HOME). Is your home…

Owned or being bought by you or someone in your household…1

Rented by you or someone in your household, or 2

Occupied without payment of rent? 3

SOME OTHER ARRANGEMENT…………………………... -5(OWN_HOME_OTH) REFUSED…………………………………………………….. -1

DON’T KNOW -2

HC002A/(OWN_HOME_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_8) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS: THE REST OF THE QUESTIONS IN THIS SECTION ARE ONLY ASKED OF A SUBSET OF RESPONDENTS, DEPENDING UPON WHETHER A PRE-PREGNANCY QUESTIONNAIRE WAS COMPLETED AND RESPONSES TO (RECENT_MOVE) ABOVE AND DURING THE PRE-PREGNANCY VISIT

IF (RECENT_MOVE) DURING THIS EVENT IS “YES” GO TO (AGE_HOME) AND CONTINUE THROUGH REST OF SECTION

IF (RECENT_MOVE) DURING THIS EVENT IS ‘NO,’ REFUSED,’ OR ‘DON’T KNOW’ AND

• NO PRE-PREGNANCY INFORMATION IS AVAILABLE; GO TO (AGE_HOME) AND CONTINUE THROUGH REST OF SECTION

• IF (RECENT_MOVE) WAS ASKED DURING PRE-PREGNANCY QUESTIONNAIRE AND WAS CODED AS “YES”; SKIP REST OF SECTION AND GO TO (TIME_STAMP_9)

• IF (RECENT_MOVE) WAS ASKED DURING PRE-PREGNANCY QUESTIONNAIRE AND WAS NOT CODED AS “YES”; GO TO (AGE_HOME) AND CONTINUE THROUGH SECTION

HC004/(AGE_HOME). Can you tell us, which of these categories do you think best describes when your home or building was built?

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?

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 HEATING SOURCE 9 (HC011) /(COOLING)

OTHER -5 (MAIN_HEAT _OTH)

REFUSED -1 (HC011) /(COOLING)

DON’T KNOW -2 (HC011) /(COOLING)

INTERVIEWER INSTRUCTION: SHOW RESPONSE OPTIONS ON CARD TO RESPONDENT.

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?

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

OTHER -5 (HEAT2_OTH)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO RESPONDENT.

• PROBE FOR ANY OTHER RESPONSES

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_9)

REFUSED -1 (TIME_STAMP_9) DON’T KNOW -2 (TIME_STAMP_9)

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

Some other cooling system -5 (COOL_OTH)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: PROBE FOR ANY OTHER RESPONSES

HC012A. (COOL_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_9) 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

Filtered tap water, 2

Bottled water, or 3

Some other source? -5 (WATER_DRINK_OTH)

REFUSED -1

DON’T KNOW -2

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

Filtered tap water, 2

Bottled water, or 3

Some other source? -5 (WATER_COOK _OTH)

REFUSED -1

DON’T KNOW -2

HC035A. (WATER_COOK _OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

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) In the past 12 months, have you seen any water damage inside your home?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

HC019/(MOLD). In the past 12 months, 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_10)

REFUSED -1 (TIME_STAMP_10)

DON’T KNOW -2 (TIME_STAMP_10)

HC020. /(ROOM_MOLD) In which rooms have you seen the mold or mildew?

PROBE: Any other rooms?

SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

RESPONDENT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5 (ROOM_MOLD _OTH)

REFUSED -1

DON’T KNOW -2

HC020A. (ROOM_MOLD OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_10) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC021. The next few questions ask about any recent additions or renovations to your home.

HC022/(PRENOVATE). Since you became pregnant, 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 re-finishing floors.

YES 1

NO 2 (HC025) /(PDECORATE).

REFUSED -1 (HC025) /(PDECORATE).

DON’T KNOW -2 (HC025) /(PDECORATE).

HC024./ (PRENOVATE_ROOM) Which rooms were renovated?

PROBE: Any others?

SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

RESPONDENT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER (PRENOVATE_ROOM_OTH) -5

REFUSED -1

DON’T KNOW -2

HC024A/(PRENOVATE_ROOM_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC025/(PDECORATE). Since you became pregnant, were any smaller projects done in your home, such as painting, wallpapering, refinishing floors, or installing new carpet?

YES 1

NO 2 (TIME_STAMP_11)

REFUSED -1 (TIME_STAMP_11)

DON’T KNOW -2 (TIME_STAMP_11)

HC026/(PDECORATE_ROOM) . In which rooms were these smaller projects done?

PROBE: Any others?

SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

RESPONDENT’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER (PDECORATE_ROOM_OTH) -5

REFUSED -1

DON’T KNOW -2

HC026A/(PDECORATE_ROOM_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PETS

(TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PP001. Now I’d like to ask about any pets you may have in your home.

PP002/(PETS). Are there any pets that spend any time inside your home?

YES 1

NO 2 (TIME_STAMP_12)

REFUSED -1 (TIME_STAMP_12)

DON’T KNOW -2 (TIME_STAMP_12)

PP003/(PET_TYPE).What kind of pets are these?

SELECT ALL THAT APPLY.

DOG 1

CAT 2

SMALL MAMMAL (RABBIT, GERBIL, HAMSTER,

GUINEA PIG, FERRET, MOUSE) 3

BIRD 4

FISH OR REPTILE (TURTLE, SNAKE, LIZARD) 5

OTHER (PET_TYPE_OTH) -5

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: PROBE FOR ANY OTHER RESPONSES

PP003A./(PET_TYPE_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HOUSEHOLD COMPOSITION AND DEMOGRAPHICS

(TIME_STAMP_12) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

OH000. Now, I’d like to ask some questions about your schooling and employment.

PROGRAMMER INSTRUCTION: IF A PRE-PREGNANCY QUESTIONNAIRE WAS COMPLETED ADD TEXT: “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.”

OH00A/(EDUC). What is the highest degree or level of school that you have completed?

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1

HIGH SCHOOL DIPLOMA OR GED 2

SOME COLLEGE BUT NO DEGREE 3

ASSOCIATE DEGREE 4

BACHELOR’S DEGREE (e.g., BA, BS) 5

POST GRADUATE DEGREE (e.g., Masters or Doctoral)...6

REFUSED -1

DON’T KNOW -2

OH001/(WORKING) Are you currently working at any full or part time jobs?

YES 1 (HOURS)

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: IF (WORKING) = 2, -1, -2 SKIP TO INTRO SENTENCE BEFORE (COMMUTE)/ CO001

OH002a/(HOURS). . Approximately how many hours each week are you working?

|___|___|___|

NUMBER OF HOURS

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: INCLUDE A SOFT EDIT IF RESPONSE > 60

OH002b/(SHIFT_WORK) . Do you work a shift that starts after 2 pm?

YES 1

NO 2

SOMETIMES 3

REFUSED -1

DON’T KNOW -2

DM001 These next questions are about the language spoken to your baby.

DM003 (HH_NONENGLISH) Is there any language other than English regularly spoken in your home?

YES	………………………………………	1
NO	………………………………………	2	(TIME_STAMP_17)
REFUSED	………………………………………	-1	(TIME_STAMP_17)
DON’T KNOW	………………………………………	-2	(TIME_STAMP_17)

DM005 (HH_NONENGLISH_2) What languages other than English are spoken in your home?

INTERVIEWER INSTRUCTION: PROBE AS NEEDED; “Any others?”

SPANISH 1

ARABIC 2

CHINESE 3

FRENCH 4

FRENCH CREOLE 5

GERMAN 6

ITALIAN 7

KOREAN 8

POLISH 9

RUSSIAN 10

TAGALOG 11

VIETNAMESE 12

URDU 13

PUNJABI 14

BENGALI 15

FARSI 16

SIGN LANGUAGE 17

OTHER -5 (HH_NONENGLISH_2OTH)

REFUSED -1

DON’T KNOW -2

DM007 (HH_NONENGLISH_2OTH) OTHER SPECIFY

DM009 (HH_ENGLISH) Is English also spoken in your home?

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

DM011 (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

SIGN LANGUAGE 18

CANNOT CHOOSE 19

OTHER -5 (HH_PRIMARY_LANG_OTH)

REFUSED -1

DON’T KNOW -2

DM013 (HH_PRIMARY_LANG_OTH) OTHER SPECIFY

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

DM017 (TIME_STAMP_17) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

COMMUTING

CO001. Next, I’ll be asking about commuting and how you travel from place to place.

CO002/(COMMUTE). Think of the longest regular commute that you take, to work, school, or other places. By regular commute, I mean someplace that you travel to at least 3 days a week. Since you became pregnant, how do you normally get to your destination?

SELECT ALL THAT APPLY

CAR 1

BUS 2

TRAIN, SUBWAY, RAIL, OR LIGHT RAIL 3

WALK, BIKE (NON-MOTORIZED) 4

DOES NOT HAVE A REGULAR COMMUTE 5 (CO004)/(LOCAL_TRAV)

OTHER (COMMUTE_OTH) -5

REFUSED -1 (CO004)/(LOCAL_TRAV)

DON’T KNOW -2 (CO004)/(LOCAL_TRAV)

INTERVIEWER INSTRUCTION: PROBE FOR ANY OTHER RESPONSES

CO002A. (COMMUTE_OTH)

SPECIFY _____________________________

REFUSED -1 (CO004)/(LOCAL_TRAV)

DON’T KNOW -2 (CO004)/(LOCAL_TRAV)

CO003/(COMMUTE_TIME) . About how many minutes is this commute, one way? Be sure to include any routine side trips you make on the way, such as stops at day care or school. Include only the time spent driving or sitting inside the car.

|___|___|___|

NUMBER OF MINUTES

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: INCLUDE SOFT EDIT IF RESPONSE > 60

CO004/(LOCAL_TRAV) . Since you became pregnant, how do you normally get to other places, for example, shopping, doctor, visiting friends, or church?

SELECT ALL THAT APPLY.

CAR 1

BUS 2

TRAIN, SUBWAY, RAIL, OR LIGHT RAIL 3

WALK, BIKE (NON-MOTORIZED) 4

OTHER -5 (LOCAL_TRAV_OTH)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: PROBE FOR ANY OTHER RESPONSES

CO004A/(LOCAL_TRAV_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

CO005. Next, I’d like to find out about how often you pump gasoline.

CO006/(PUMP_GAS) . Since you became pregnant, about how often have you pumped or poured gasoline into a car, truck, motorcycle, other motor vehicle, lawnmower, or other engine:

Every day, 1

4-6 times per week, 2

2-3 times per week, 3

Once a week, 4

One to three times a month, 5

Less than once a month, or 6

Never? 7

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_13) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

DE004A. The next questions may be similar to those asked the last time we contacted you, but

we are asking them again because sometimes the answers change.

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

Married, 1

Not married but living together with a partner 2

Never been married, 3 (TIME_STAMP_14)

Divorced, 4 (TIME_STAMP_14)

Separated, or 5 (TIME_STAMP_14)

Widowed? 6 (TIME_STAMP_14)

REFUSED -1 (TIME_STAMP_14)

DON’T KNOW -2 (TIME_STAMP_14)

INTERVIEWER INSTRUCTION: PROBE FOR CURRENT MARITAL STATUS

DE005/(SP_EDUC). What is the highest degree or level of school that your spouse or partner has completed?

LESS THAN A HIGH SCHOOL DIPLOMA OR GED 1

HIGH SCHOOL DIPLOMA OR GED 2

SOME COLLEGE BUT NO DEGREE 3

ASSOCIATE DEGREE 4

BACHELOR’S DEGREE (e.g., BA, BS) 5

POST GRADUATE DEGREE (e.g., Masters or Doctoral) 6

REFUSED -1

DON’T KNOW -2

DE006(SP_ETHNICITY) . Does your spouse or partner consider himself [OR HERSELF, IF VOLUNTEERED] to be Hispanic, or Latino [LATINA]?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

DE007(SP_RACE) What race does your spouse (or partner) consider himself [OR HERSELF, IF VOLUNTEERED] to be? You may select one or more.

PROBE: Anything else?

SELECT ALL THAT APPLY. ONLY USE “SOME OTHER RACE” IF VOLUNTEERED. DON’T ASK

White, 1

Black or African American, 2

American Indian or Alaska Native, 3

Asian, or 4

Native Hawaiian or Other Pacific Islander? 5

SOME OTHER RACE? (SP_RACE_OTH) -5

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• SHOW RESPONSE OPTIONS ON CARD TO RESPONDENT.

• PROBE FOR ANY OTHER RESPONSES

DE007a/ (SP_RACE_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

FAMILY INCOME

(TIME_STAMP_14) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

DE009.Now I’m going to ask a few questions about your income. Family income is important in analyzing the data we collect and is often used in scientific studies to compare groups of people who are similar. Please remember that all the information you provide 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?

|___|___|

NUMBER

REFUSED -1 (DE011)/ (INCOME)

DON’T KNOW -2 (DE011)/ (INCOME)

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

DE010A. (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

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• INCLUDE HARD EDIT IF RESPONSE > HH_MEMBERS

• INCLUDE SOFT EDIT IF RESPONSE > 10

DE011. (INCOME) Of these income groups, which category best represents your combined family income during the last calendar year?

INTERVIEWER INSTRUCTION: SHOW RESPONDENT CATEGORIES ON SHOW CARD

Less than $4,999 1 (TIME_STAMP_15)

$5,000-$9,999 2 (TIME_STAMP_15)

$10,000-$19,999 3 (TIME_STAMP_15)

$20,000-$29,999 4 (TIME_STAMP_15)

$30,000-$39,999 5 (TIME_STAMP_15)

$40,000-$49,999 6 (TIME_STAMP_15)

$50,000-$74,999 7 (TIME_STAMP_15)

$75,000-$99,999 8 (TIME_STAMP_15)

$100,000-$199,000 9 (TIME_STAMP_15)

$200,000 or more 10 (TIME_STAMP_15)

REFUSED -1(TIME_STAMP_15)

DON’T KNOW -2 (TIME_STAMP_15)

TRACING QUESTIONS

(TIME_STAMP_15) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TR000. 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.

PROGRAMMER INSTRUCTIONS: ASK (COMM_EMAIL) ONLY IF A PRE-PREGNANCY INTERVIEW WAS COMPLETED; ELSE SKIP TO (HAVE_EMAIL)

TR000A/(COMM_EMAIL). When we last spoke, we asked questions about communicating with you through your personal email. Has your email address or your preferences regarding use of your personal email changed since then?

YES ………………………………………………………………………1

NO ………………………………………………………………………2 (COMM_CELL)

DON’T REMEMBER ………………………………………………….. 3

REFUSED …………………………………………………………….. -1

DON’T KNOW ………………………………………………………….-2

TR101/(HAVE_EMAIL). 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 ADDRES SUCH AS [email protected]

ENTER E-MAIL ADDRESS: ___________________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS: ASK (COMM_CELL) ONLY IF A PRE-PREGNANCY INTERVIEW WAS COMPLETED AND; ELSE SKIP TO (CELL_PHONE_1)

TR105A/(COMM_CELL). When we last spoke, we asked questions about communicating with you through your personal cell phone number. Has your cell phone number or your preferences regarding use of your personal cell phone number changed since then?

YES 1

NO 2 (TIME_STAMP_16)

DON’T REMEMBER 3

REFUSED -1

DON’T KNOW -2

TR105/(CELL_PHONE_1). Do you have a personal cell phone?

YES 1

NO 2 (TIME_STAMP_16)

REFUSED -1 (TIME_STAMP_16)

DON’T KNOW -2 (TIME_STAMP_16)

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

RESPONDENT HAS NO CELL PHONE 1

REFUSED -1

DON’T KNOW -2

(TIME_STAMP_16) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS: ASK (COMM_CONTACT) ONLY IF A PRE-PREGNANCY INTERVIEW WAS COMPLETED; ELSE SKIP TO (CONTACT_1)

TR001A/ (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 (TR010)/(END)

DON’T REMEMBER 3

REFUSED -1

DON’T KNOW -2

TR001/(CONTACT_1). 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)

TR002./(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 RESPONDENT DOES NOT WANT TO PROVIDE NAME OF CONTACT ASK FOR INITIALS

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TR014/(CONTACT_RELATE_1).What is his/her relationship to you?

MOTHER/FATHER 1

BROTHER/SISTER 2

AUNT/UNCLE 3

GRANDPARENT 4

NEIGHBOR 5

FRIEND 6

OTHER (CONTACT_RELATe1 _OTH) -5

REFUSED -1

DON’T KNOW -2

Tr014a./ (CONTACT_RELATe1_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

TR003./(CONTACT_ADDR_1).What is his/her address?

INTERVIEWER INSTRUCTIONS:

PROMPT AS NECESSARY TO COMPLETE INFORMATION

____________________________________________________

STREET (c_ADDR1_1)/(c_ADDR_2_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

TR004(CONTACT_PHONE_1) What is his/her telephone number?

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

PHONE NUMBER

CONTACT HAS NO TELEPHONE 1

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

TR005/(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 (TR010)/(end)

REFUSED -1 (TR010)/(end)

DON’T KNOW -2 (TR010)/(end)

INTERVIEWER INSTRUCTION:

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

• CONFIRM SPELLING OF FIRST AND LAST NAMES.

TR006/(CONTACT_RELATE_2)..What is his/her relationship to you?

MOTHER/FATHER 1

BROTHER/SISTER 2

AUNT/UNCLE 3

GRANDPARENT 4

NEIGHBOR 5

FRIEND 6

OTHER (CONTACT_relate2_oth) -5

REFUSED -1

DON’T KNOW -2

tr006a/(CONTACT_relate2_oth)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

TR007/(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

TR008/(CONTACT_PHONE_2).. what is his/her telephone number?

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

PHONE NUMBER

CONTACT HAS NO TELEPHONE 1 (TR010)/(end)

REFUSED -1 (TR010) /(end)

DON’T KNOW -2 (TR010) /(end)

INTERVIEWER INSTRUCTION: IF CONTACT HAS NO TELEPHONE ASK FOR TELEPHONE NUMBER WHERE HE/SHE RECEIVES CALLS

TR009/(eND_LOSS). Again, I’d like to say how sorry I am for your loss. [IF LOSS_INFO = YES SAY {We’ll send the information packet you requested as soon as possible.}] Please accept our best wishes for a quick recovery. Thank you for your time.

INTERVIEWER INSTRUCTION: IF LOSS OF PREGNANCY, END INTERVIEW. DO NOT ADMINISTER SAQs.

TR010/(END). Thank you for participating in the National Children’s Study and for taking the time to complete this survey. This concludes the interview portion of our visit.

INTERVIEWER INSTRUCTION: explain SAQS and RETURN process

(TIME_STAMP_17) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

INTERVIEWER INSTRUCTION: EXPLAIN PREGNANCY HEALTH CARE LOG

In order to help you keep track of your doctor visits or other health care provider visits during your pregnancy, we are giving you a Pregnancy Health Care Log. At each Study visit or telephone interview, we will ask you about any health care visits you had since the last Study visit or telephone interview. This log will help you remember that information. The Pregnancy Health Care Log has a Health Care Provider Log section for writing down information about your health care providers; address and phone numbers, and there is also a Health Care Visits and Overnight Hospital Stays section for keeping track of information about your health care visits and any diagnoses, procedures, or treatments.

It will be very helpful if you use the log to write down information any time that you receive health care, so that you will be able to remember it accurately during your NCS Study visits or telephone interviews.

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.