Form 28.1 Survey

OMB #: 0925-0593

Expiration Date: 07/31/2013

18-Month Mother Interview, Phase II

Recruitment Strategy Substudy

Event Name(s):

18-Month Mother Interview (EH, PB, HI)

Instrument Name(s) and Versions:

18-Month Mother Interview (EH, PB, HI) – 1.0

Recruitment Groups:

Enhanced Household, Provider-Based, High Intensity

18-Month Mother Interview (EH, PB, HI)

18-Month Mother Interview (EH, PB, HI)

TABLE OF CONTENTS

INTERVIEW INTRODUCTION 3

PARTICIPANT VERIFICATION 5

DEMOGRAPHICS…………………………………………………………………………………………………………………6

SLEEP………………………………………………………………………………………………………………………………9

CHILD CARE ARRANGEMENTS 11

HEALTH CARE 13

MEDICAL CONDITIONS 16

MEDICATIONS 18

PRODUCT USE…………………………………………………………………………………………………………………. 23

MATERNAL BEHAVIORS …………………………………………………………………………………………………….. 24

PETS………………………………………………………………………………………………………………………………26

IN-HOME EXPOSURES 27

HOUSING CHARACTERISTICS ………………………………………………………………………………………………30

NEIGHBORHOOD CHARACTERISTICS 33

TRACING QUESTIONS 39

18-Month Mother Interview (EH, PB, HI)

CAPI

Interview Introduction

(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IN001 Thank you again for agreeing to participate in the National Children’s Study. We are about to begin the interview portion of today’s home visit, which 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 about yourself, your {CHILD/CHILDREN}, your health, where you live, and your feelings about being a part of the National Children’s Study. You can skip over any questions or stop the interview at any time. We will keep everything that you tell us confidential.

INTERVIEWER-COMPLETED QUESTIONS

IN004 (MULT_CHILD) IS THERE MORE THAN ONE CHILD OF THIS MOTHER ELIGIBLE FOR THE 18 MONTH VISIT TODAY?

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

IN005 (CHILD_NUM) HOW MANY CHILDREN OF THIS MOTHER ARE ELIGIBLE FOR THE 18 MONTH VISIT 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 MALE OR FEMALE?

MALE	…………………………………………………….	1
FEMALE	…………………………………………………….	2

PROGRAMMER INSTRUCTION: USE CHILD_SEX TO CODE {his/her} AND {he/she} FIELDS AS APPROPRIATE THROUGHOUT INSTRUMENT

Participant Verification

INTERVIEWER INSTRUCTION: IF (CHILD_QNUM) >1, SAY, “I’d like to ask about your next child.”

PV001 First, we’d like to make sure we have your child’s correct name and birth date.

PV004 (CNAME_CONFIRM). Is your child’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

PV007 (C_FNAME) (C_LNAME) What is your child’s full name?

_________________________ _________________________

FIRST NAME LAST NAME

(C_FNAME) (C_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.

PROGRAMMER INSTRUCTIONS: IF RESPONDENT REFUSES TO PROVIDE NAME, INITIALS OR IDENTIFIER (C_FNAME AND C_LNAME= -1 OR -2), USE “YOUR CHILD” FOR “C_FNAME” In remainder of questionnaire.

PV011 (CDOB_CONFIRM). Is {C_FNAME or YOUR CHILD}’S birth date [INSERT CHILD’S DATE OF BIRTH]?

YES	…………………………………	1	(PREGNANT)
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

PV016 (CHILD_DOB). What is {C_FNAME or YOUR CHILD }’s date of birth?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED	…………………………………	-1	(PREGNANT)
DON’T KNOW	…………………………………	-2	(PREGNANT)

INTERVIEWER INSTRUCTION:

• 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 INSTRUCTION:

• INCLUDE A SOFT EDIT/WARNING IF CALCULATED AGE IS LESS THAN 16 MONTHS OR GREATER THAN 22 MONTHS

• FORMAT CHILD_DOB AS YYYYMMDD

• IF CHILD_QNUM >1, GO TO (TIME_STAMP_3)

PS004 (PREGNANT) IF ADULT IS KNOWN TO BE PREGNANT, ADD [Just to confirm,] Are you pregnant now?

YES 1 (ORIG_DUE_DATE)

NO, NO ADDITIONAL INFORMATION PROVIDED 2 (TIME_STAMP_2)

(IF VOLUNTEERED BY RESPONDENT)

NO, RECENTLY LOST PREGNANCY

(MISCARRIAGE/ABORTION) …3 (PREG_LOSS)

NO, RECENTLY GAVE BIRTH………………………………….…4 (TIME_STAMP_2);

NO, UNABLE TO HAVE CHILDREN (HYSTERECTOMY,

TUBAL LIGATION)………………………………………………5 (TIME_STAMP_2)

REFUSED ………………………..…………………………………..-1 (TIME_STAMP_2)

DON’T KNOW………………………………………………………..-2 (TIME_STAMP_2)

PREG_LOSS I’m so sorry for your loss. Please accept our sincere wishes at this difficult time. (TIME_STAMP_2)

PS006 (ORIG_DUE_DATE) [Congratulations.] When is your baby due?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1 (PS008) (TIME_STAMP_2)

DON’T KNOW -2 (PS008) (TIME_STAMP_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

DEMOGRAPHICS

(TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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

Divorced, 4

Separated, or 5

Widowed? 6

REFUSED -1

OTHER -5 (MARISTAT_OTH)

DE004A (MARISTAT_OTH) OTHER: SPECIFY _____________________________________

INTERVIEWER INSTRUCTION: RECORD THE RESPONDENT’S CURRENT MARITAL STATUS

DE005 (HHCOMP_CHANGE) Have there been any changes in your household members since we contacted you last?

YES	……………………………………………	1	(DE006/HHCOMP_CHANGE_SPECIFY)
NO	……………………………………………	2	(DE009)
REFUSED	……………………………………………	-1	(DE009)
DON’T KNOW	……………………………………………	-2	(DE009)

DE006 (HHCOMP_CHANGE_SPECIFY). Please explain.

INTERVIEWER INSTRUCTION:

[ALLOW UP TO 250 ALPHANUMERIC CHARACTERS.]

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

REFUSED -1

DON’T KNOW -2

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?

|___|___| (NUM_CHILD)

NUMBER

REFUSED -1 INCOME)

DON’T KNOW -2 (INCOME)

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

DE010 (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 (INCOME)

REFUSED -1 (INCOME)

DON’T KNOW -2 (INCOME)

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 total combined family income during the last calendar year?

Less than $30,000 1

$30,000-$49,999 2

$50,000-$99,999 3

$100,000 or more 4

REFUSED -1

DON’T KNOW -2

Sleep

SL012 (TIME_STAMP_3) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

SL013 I’m now going to ask you about {C_FNAME or YOUR CHILD}’s sleeping habits.

SL014 (SLEEP_HRS_DAY) Approximately how many hours does {C_FNAME or YOUR CHILD} sleep during the day?

|___|___|

HOURS

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

SL016 (SLEEP_HRS_NIGHT) Approximately how many hours does {C_FNAME or YOUR CHILD} sleep at night?

|___|___|

HOURS

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

SL018 (SLEEP_TIME_NIGHT) On a normal day, what time in the evening does {C_FNAME or YOUR CHILD} go to sleep?

|___|___|:|___|___|

TIME

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

SL020 (SLEEP_TIME_WAKE) On a normal day, what time does {C_FNAME or YOUR CHILD} wake up in the morning?

|___|___|:|___|___|

TIME

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

SL022 (SLEEP_DIFFICULT) How often is {C_FNAME or YOUR CHILD} difficult when {he/she}

is put to bed?

Most of the time ……………………………………………………………. 1

Often ………………………………………………………………………… 2

Sometimes …………………………………………………………………. 3

Rarely ……………………………………………………………………….. 4

Never ……………………………………………………………………….. 5

REFUSED ………………………………………………………………… -1

DON’T KNOW……………………………………………………………… -2

SL024 (SLEEP_THROUGH) How often does {C_FNAME or YOUR CHILD} wake at night?

Never ……………………………………………………………………….. 1

Occasionally ……………………………………………………………….. 2

Most nights ………………………………………………………………… 3

Every night …………………………………………………………………. 4

More than once per night …………………………………………………. 5

REFUSED ………………………………………………………………… -1

DON’T KNOW …………………………………………………………….. -2

CDP 068 (TV_FREQ) Over the past 30 days, on average, how many hours per day did {C_FNAME or YOUR CHILD } sit and watch TV and/or DVDs? Would you say …

Less than 1 hour, 1

2 hours 2

3 hours, 3

4 hours, 4

5 hours or more, or 5

None, {C_FNAME or YOUR CHILD} does not watch TV or DVDs 6

REFUSED -1

DON’T KNOW -2

Child Care Arrangements

(TIME_STAMP_4) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

CC001 (CHILDCARE_CHANGE) Has there been a change in your childcare arrangements since our last interview?

YES	……………………………………………	1
NO	……………………………………………	2	(TIME_STAMP_5)
REFUSED	……………………………………………	-1	(TIME_STAMP_5)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_5)

CC003 I’d like to ask you about different types of child care {C_FNAME or YOUR CHILD} may receive from someone other than parents or guardians. This includes regularly scheduled care arrangements with relatives and non-relatives, and day care or early childhood programs, whether or not there is a charge or fee, but not occasional baby-sitting.

CC005 (CHILDCARE) Does {C_FNAME or YOUR CHILD} currently receive any regularly scheduled care from someone other than a parent or guardian, for example from relatives, friends or other non-relatives, or a child care center or program?

YES	……………………………………………	1
NO	……………………………………………	2	(TIME_STAMP_5)
REFUSED	……………………………………………	-1	(TIME_STAMP_5)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_5)

CC008 (FAMILY_CARE) Does {C_FNAME or YOUR CHILD} receive any care from relatives, for example, from grandparents, brothers or sisters, or any other relatives. This includes all regularly scheduled care arrangements with relatives that happen at least weekly, but does not include occasional baby-sitting.

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

CC011 (FAMILY_CARE_HRS) Approximately how many total hours each week does {C_FNAME or YOUR CHILD} receive care from relatives?

|___|___|

NUMBER OF HOURS PER WEEK

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

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF RESPONSE EXCEEDS 50 HOURS PER WEEK

CC014 Now I’d like to ask you about any regularly scheduled care {C_FNAME or YOUR CHILD} receives from someone not related to {him/her}, either in your home or someone else’s home. This includes all regularly scheduled care arrangements with non-relatives that happen at least weekly, including home child care providers, regularly scheduled sitter arrangements, or neighbors. This does not include day care centers, early childhood programs, or occasional babysitting.

CC017 (HOMECARE) Does {C_FNAME or YOUR CHILD} receive any regularly scheduled care either in your home or someone else’s home from someone not related to {him/her}?

INTERVIEWER INSTRUCTION: IF NECESSARY READ… “This includes arrangements with non-relatives including home child care providers, regularly scheduled sitter arrangements, or neighbors. This does not include day care centers, early childhood programs, or occasional babysitting.”

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

CC020 (HOMECARE_HRS) Approximately how many total hours each week does {C_FNAME or YOUR CHILD} receive care in a home from non-relatives?

|___|___|

NUMBER OF HOURS PER WEEK

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

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF RESPONSE EXCEEDS 50 HOURS PER WEEK

CC023 Now I want to ask you about child care centers {C_FNAME} may attend on a regular basis. Such centers include day care centers, early learning centers, nursery schools, and preschools.

CC026 (DAYCARE) Does {C_FNAME or YOUR CHILD} receive any care in child care centers? Such centers include day care centers, early learning centers, nursery schools, and preschools.

YES	……………………………………………	1
NO	……………………………………………	2	(TIME_STAMP_5)
REFUSED	……………………………………………	-1	(TIME_STAMP_5)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_5)

CC029 (DAYCARE_HRS) Approximately how many total hours each week does {C_FNAME or YOUR CHILD} receive care in child care centers?

|___|___|

NUMBER OF HOURS PER WEEK

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

PROGRAMMER INSTRUCTION: INCLUDE SOFT EDIT IF RESPONSE EXCEEDS 50 HOURS PER WEEK

Health Care

(TIME_STAMP_5) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC001 The next questions are about where {C_FNAME or YOUR CHILD} goes for health care.

HC004 (R_HCARE). First, what kind of place does {C_FNAME or 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
REFUSED	………………………	-1
DON’T KNOW	………………………	-2

MC003 (C_HEALTH) Would you say {C_FNAME or YOUR CHILD}’s health is poor, fair, good, or excellent?

POOR	…………………………………………………..	1
FAIR	…………………………………………………..	2
GOOD	………………………………………………….	3
EXCELLENT	…………………………………………………..	4
REFUSED	…………………………………………………..	-1
DON’T KNOW	…………………………………………………..	-2

PROGRAMMER INSTRUCTION: IF (R_HCARE) = 7, -1, OR 1-, GO TO HOSPITAL. OTHERWISE, GO TO (LAST_VISIT).

FY008. Are you using the Infant and Child Health Care Log? This is the booklet that you or your health care provider (pediatrician or family medicine doctor, specialist (like a surgeon, heart, allergy, or skin doctor), nurse practitioner, physician assistant, nurse, social worker/counselor, etc.) uses to record information about your child’s medical visits.

YES 1 (FY012)

NO 2

REFUSED 9--97 (HC007)

DON’T KNOW 9--98 (HC007)

FY009. Is that because…

Your child hasn’t had a medical visit since our last interview, 1 (HC007)

You’ve misplaced the log 2 (FY010)

You’ve forgotten to bring it to your child’s medical visits 3 (FY011)

The log was too much trouble to complete, or 4 (FY011)

The log was too difficult to understand? 5 (HC007)

OTHER (SPECIFY): 6

REFUSED 9--97 (FY011)

DON’T KNOW 9—98 (FY011)

FY009A. OTHER: SPECIFY _____________________________________ (HC007)

FY010. We’ll get another Infant and Child Health Care Log in the mail to you today. (HC007)

FY011. 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 child’s medical visits. (HC007)

FY012 How many health care providers has your child seen since using this Infant and Child Health Care Log?

|___|___|

NUMBER OF PROVIDERS

REFUSED 9--97

DON’T KNOW 9--98

FY013 Of those providers that your child has seen, how many providers have you recorded their contact information such as address or phone number?

|___|___|

NUMBER OF CONTACTS

REFUSED 9--97

DON’T KNOW 9--98

DV001. I am now going to ask some questions about your child’s visits to a doctor or other health care provider (pediatrician or family medicine doctor, specialist (like a surgeon, heart, allergy, or skin doctor). It would be helpful if you referred to the Infant and Child 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.

HC007 (LAST_VISIT) What was the date of {C_FNAME or YOUR CHILD}’s most recent well-child visit or checkup?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

HAS NOT HAD A VISIT		1	(HOSPITAL)
REFUSED	………………………………	-1	(HOSPITAL)
DON’T KNOW	………………………………	-2	(HOSPITAL)

INTERVIEWER INSTRUCTION:

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

HC010 (VISIT_WT) What was {C_FNAME or YOUR CHILD}’s weight at that visit?

|___|___|

Pounds

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

PROGRAMMER INSTRUCTION: INCLUDE A SOFT EDIT IF WEIGHT < 15 OR > 30 POUNDS

FY027. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Infant and Child Health Care Log.

HC017 (HOSPITAL). Since our last interview, has {C_FNAME or YOUR CHILD} spent at least one night in the hospital?

YES 1 (ADMIN_DATE)

NO 2 (TIME_STAMP_6)

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW -2 (TIME_STAMP_6)

HC018 (ADMIN_DATE). What was the admission date of {C_FNAME or YOUR CHILD}’s most recent hospital stay?

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

HC019 (HOSP_NIGHTS). How many nights did {C_FNAME or YOUR CHILD} stay in the hospital during this hospital stay?

|___|___|___|

NUMBER OF NIGHTS

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: CONFIRM RESPONSE

HC020 (DIAGNOSE). Did a doctor or other health care provider give you a diagnosis for {C_FNAME or YOUR CHILD } during this hospital stay?

YES 1 (DIAGNOSE_2)

NO 2 (TIME_STAMP_6)

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW -2 (TIME_STAMP_6)

DV021 (DIAGNOSE_2).. What was the diagnosis?

INTERVIEWER INSTRUCTION:

ENTER ALL DIAGNOSES IN FIELD SEPARATED BY COMMAS OR AN “AND”.

PROBE: “Anything else?”

________________________________

DIAGNOSES

REFUSED -1

DON’T KNOW -2

FY027. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Infant and Child Health Care Log.

Medical Conditions

(TIME_STAMP_6) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

MC001 Now I’d like to ask about {C_FNAME or YOUR CHILD}’s health and about some illnesses {he/she} may have had in the last 3 months.

MC004 (COND) During the past 3 months, has {C_FNAME or YOUR CHILD} had any of the following conditions…

INTERVIEWER INSTRUCTION: SELECT ALL THAT APPLY

PROBE: “Anything else?”

Three or more ear infections	……………………………	1
Wheezing or whistling in the chest	……………………………	2
Frequent or repeated diarrhea	……………………………	3
REFUSED	……………………………	-1
DON’T KNOW	……………………………	-2

MC013 (FEVER) In the past 3 months, on how many days has {C_FNAME or YOUR CHILD} had a fever over 101 degrees, not related to receiving immunizations?

INTERVIEWER INSTRUCTION: IF NECESSARY READ… “or 38.3 degrees Celsius?”

|___|___|

NUMBER OF DAYS

INTERVIEWER INSTRUCTION: ENTER “0” IF NONE

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

MC015 Now I have some questions about specific conditions or health problems {C_FNAME or YOUR CHILD} may have.

MC016 (ASTHMA) Has a doctor ever told you that {C_FNAME or YOUR CHILD} has asthma?

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

MC024 (IHMOB) Does {C_FNAME or YOUR CHILD} have an impairment or health problem that limits {his/her} ability to crawl, walk, run, or play?

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

MEDICATIONS

(TIME_STAMP_7) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

MD002 Now, I’d like to ask about medications that may have been prescribed by a doctor or other healthcare provider for {C_FNAME or YOUR CHILD}.

MD003 (PRESCR_TAKE) In the past 30 days, has {C_FNAME or YOUR CHILD} used or taken any medication for which a prescription is needed? Include only those products prescribed by a health professional such as a doctor or dentist. [Do not include prescription vitamins or minerals.]

YES	……………………………………………	1	(PRESCR_LIST)
NO	……………………………………………	2	(MD008)
REFUSED	……………………………………………	-1	(MD008)
DON’T KNOW	……………………………………………	-2	(MD008)

MD004 (PRESCR _LIST) Please list the name of all prescription medications taken in the past 30 days:

INTERVIEWER INSTRUCTION: ENTER EACH MEDICATION IN A SEPARATE FIELD. ENTER UP TO 10 MEDICATIONS; IF MORE THAN 10 MEDICATIONS PROVIDED, ENTER FIRST 10 PROVIDED BY PARTICIPANT.

(PRESCRMED_1)

(PRESCRMED_2)

(PRESCRMED_3)

(PRESCRMED_4)

(PRESCRMED_5)

(PRESCRMED_6)

(PRESCRMED_7)

(PRESCRMED_8)

(PRESCRMED_9)

(PRESCRMED_10)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: PROBE: Anything else?

PROGRAMMER INSTRUCTION: IF CYCLING THROUGH FOR (PRESCRMED_1), DISPLAY (INTRO_PRESCRMED_1). OTHERWISE, IF CYCLING THROUGH FOR (PRESCRMED_2) THROUGH (PRESCRMED_10), THEN DISPLAY (PRESCRMED_2_10).

MD004A (INTRO_PRESCRMED_1) Let’s first talk about the {PRESCRMED_1).

MD004B (INTRO_PRESCRMED_2_10) Now let’s talk about the {PRESCRMED_2 to PRESCRMED_10}.

PROGRAMMER INSTRUCTION: IN (INTRO_PRESCRMED_2_10 ), (PRESCR_ADMIN), (PRESCR_TAKESTILL) and (PRESCRIP_FREQ) INSERT CORRECT MEDICATION [(PRESCRMED_1) to PRESCRMED_10) from (PRESCR _LIST)] for appropriate cycle.

MD005 (PRESCR_ADMIN) How is the {PRESCRMED_1} taken?

By mouth, 1

Inhaled either by mouth or nose, 2

Injected, 3

Applied to the skin, such as a patch or creams, or 4

Some other way? (SPECIFY): 5

REFUSED -1

DON’T KNOW -2

MD006 (PRESCR_TAKESTILL) Is {C_FNAME or YOUR CHILD} still the taking {PRESCRMED_1}?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD007 (PRESCRIP_FREQ) / PRESCRIP_FREQ_UNIT) How often {does/did} {C_FNAME or YOUR CHILD} use or take the {PRESCRMED_1}?

PROGRAMMER INSTRUCTION: If (PRESCR__TAKESTILL) = 1, DISPLAY “DOES”; OTHERWISE, DISPLAY “DID”

|___|___|

ENTER NUMBER

ENTER UNIT

PER DAY 1

PER WEEK 2

PER MONTH 3

PER YEAR 4

AS NEEDED 5

REFUSED —-1

DON’T KNOW —-2

PROGRAMMER INSTRUCTION: CYCLE THROUGH (INTRO_PRESCRMED_2_10) THROUGH (PRESCRIP_FREQ)/(PRESCRIP_FREQ_UNIT) FOR EACH PRESCRIPTION IN (PRESCR _LIST).

MD008 Now I’d like to ask about non-prescription medications, over the counter medications, and dietary supplements that {C_FNAME or YOUR CHILD} may have taken in the last 30 days.

MD009 (OTC_TAKE) Has {C_FNAME or YOUR CHILD} used or taken any non-prescription medications in the past 30 days? Include only those products purchased over the counter that do not require a prescription. [Do not include over-the –counter vitamins or minerals.]

YES	……………………………………………	1	(OTC_LIST)
NO	……………………………………………	2	(MD014)
REFUSED	……………………………………………	-1	(MD014)
DON’T KNOW	……………………………………………	-2	(MD014)

MD010 (OTC_LIST) Please list the names of all non-prescription medications taken in the past 30 days:

INTERVIEWER INSTRUCTION: ENTER EACH MEDICATION IN A SEPARATE FIELD. ENTER UP TO 10 MEDICATIONS; IF MORE THAN 10 MEDICATIONS PROVIDED, ENTER FIRST 10 PROVIDED BY PARTICIPANT.

(OTCMED_1)

(OTCMED_2)

(OTCMED_3)

(OTCMED_4)

(OTCMED_5)

(OTCMED_6)

(OTCMED_7)

(OTCMED_8)

(OTCMED_9)

(OTCMED_10)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: PROBE: Anything else?

PROGRAMMER INSTRUCTION: IF CYCLING THROUGH FOR (OTCMED_1), DISPLAY (INTRO_OTCMED_1). OTHERWISE, IF CYCLING THROUGH FOR (OTCMED_2) THROUGH (OTCMED_10), THEN DISPLAY (INTRO_OTCMED_2_10).

MD010A (INTRO_OTCMED_1) Let’s first talk about the {OTCMED_1}.

MD0010B (INTRO_OTCMED_2_10) Now let’s talk about the {OTCMED_2).

PROGRAMMER INSTRUCTION: IN (INTRO_ OTCMED _2_10 ), (OTC_ADMIN), (OTC _TAKESTILL) and (OTC _FREQ) INSERT CORRECT MEDICATION [(OTC MED_1) to (OTCMED_10) from (OTC _LIST)] for appropriate cycle.

MD011 (OTC_ADMIN) How is the {OTCMED_1} taken?

By mouth, 1

Inhaled either by mouth or nose, 2

Injected, 3

Applied to the skin, such as a patch or creams, or 4

Some other way? (SPECIFY): 5

REFUSED -1

DON’T KNOW -2

MD012 (OTC_TAKESTILL) Is {C_FNAME or YOUR CHILD } still taking the {OTCMED_1}?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD013 (OTC_FREQ)/OTC_FREQ_UNIT) How often {does/did} {C_FNAME or YOUR CHILD} use or take the {OTCMED_1}?

PROGRAMMER INSTRUCTION: If (OTC_TAKESTILL) = 1, DISPLAY “DOES”; OTHERWISE, DISPLAY “DID”

|___|___|

ENTER NUMBER

ENTER UNIT

PER DAY 1

PER WEEK 2

PER MONTH 3

PER YEAR 4

AS NEEDED 5

REFUSED —-1

DON’T KNOW —-2

PROGRAMMER INSTRUCTION: CYCLE THROUGH (INTRO_OTCMED_2_10) THROUGH(OTC_FREQ)/OTC_FREQ_UNIT) FOR EACH OVER-THE-COUNTER MEDICATION.

,MD014 Now I would like to ask about dietary supplements.

MD015 (SUPPL_TAKE) Has {C_FNAME or YOUR CHILD} used or taken any vitamins, minerals, herbals, or other dietary supplements in the past 30 days? Include only those supplements purchased over the counter that do not require a prescription.

YES	……………………………………………	1	(/SUPPL_LIST)
NO	……………………………………………	2	(TIME_STAMP_8)
REFUSED	……………………………………………	-1	(TIME_STAMP_8)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_8)

MD016 (SUPPL_LIST) Please list the names of all vitamins, minerals, herbals, and other dietary supplements taken in the past 30 days:

INTERVIEWER INSTRUCTION: ENTER EACH SUPPLEMENT IN A SEPARATE FIELD. ENTER UP TO 10 SUPPLEMENTS; IF MORE THAN 10 SUPPLEMENTS PROVIDED, ENTER FIRST 10 PROVIDED BY PARTICIPANT.

(SUPPLMED_1)

(SUPPLMED_2)

(SUPPLMED_3)

(SUPPLMED_4)

(SUPPLMED_5)

(SUPPLMED_6)

(SUPPLMED_7)

(SUPPLMED_8)

(SUPPLMED_9)

(SUPPLMED_10)

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION: PROBE: Anything else?

PROGRAMMER INSTRUCTION: IF CYCLING THROUGH FOR (SUPPLMED_1), DISPLAY (INTRO_SUPPLMED_1). OTHERWISE, IF CYCLING THROUGH FOR (SUPPLMED_2) THROUGH (SUPPLMED_10), THEN DISPLAY (SUPPLMED_2_10).

MD016A (INTRO_SUPPLMED_1) Let’s first talk about the {SUPPLMED_1).

MD016B (INTRO_SUPPLMED_2_10) Now let’s talk about the {SUPPLMED_2).

PROGRAMMER INSTRUCTION: IN (INTRO_ SUPPLMED _2_10 ), (SUPPL_ADMIN), (SUPPL _TAKESTILL) and (SUPPL _FREQ) INSERT CORRECT MEDICATION [(SUPPL MED_1) to (SUPPLMED_10) from (SUPPL_LIST)] for appropriate cycle.

MD017 (SUPPL_ADMIN) How is the {SUPPL_1} taken?

By mouth, 1

Inhaled either by mouth or nose, 2

Injected, 3

Applied to the skin, such as a patch or creams, or 4

Some other way? (SPECIFY): 5

REFUSED -1

DON’T KNOW -2

MD018 (SUPPL_TAKESTILL) Is {C_FNAME or YOUR CHILD} still taking the {SUPPL_1}?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

MD019 (SUPPL_FREQ)/SUPPL_FREQ_UNIT) How often {does/did} {C_FNAME or YOUR CHILD} use or take the {SUPPL_1}?

PROGRAMMER INSTRUCTION: If (SUPPL_TAKESTILL) = 1, DISPLAY “DOES”; OTHERWISE, DISPLAY “DID”

|___|___|

ENTER NUMBER

ENTER UNIT

PER DAY 1

PER WEEK 2

PER MONTH 3

PER YEAR 4

AS NEEDED 5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION: CYCLE THROUGH (INTRO_SUPPLMED_2_10) THROUGH(SUPPL_FREQ) /SUPPL_FREQ_UNIT) FOR EACH SUPPLEMENT IN (SUPPL_LIST)

Product Use

(TIME_STAMP_8) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

PU001 The next questions ask about lice exposure and treatment.

PU008 (LICE_1) In the past 6 months, have you treated {C_FNAME or YOUR CHILD} or other people in your home for lice or scabies?

YES	……………………………………………	1
NO	……………………………………………	2	(TIME_STAMP_9)
REFUSED	……………………………………………	-1	(TIME_STAMP_9)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_9)

PU010 (LICE_2) Who did you treat, was it {C_FNAME or YOUR CHILD}, someone else, or both?

{C_FNAME or YOUR CHILD}	……………………	1
SOMEONE ELSE	……………………	2	(LICE_OTH_1)
BOTH {C_FNAME or YOUR CHILD} AND SOMEONE ELSE	……………………	3	(LICE_OTH_2)
REFUSED	……………………	-1
DON’T KNOW	……………………	-2

PU013 (LICE_OTH_1) OTHER: SPECIFY _______________________________

PU014 (LICE_OTH_2) OTHER: SPECIFY _______________________________

PU015 (LICE_OTH_3) OTHER: SPECIFY _______________________________

INTERVIEWER INSTRUCTION: PROBE: “Anyone else?”

MATERNAL Behaviors

PROGRAMMER INSTRUCTION: IF (CHILD_QNUM) =1, GO TO (TIME_STAMP_9). IF(CHILD_QNUM ) > 1, THEN GO TO HB012 (SMOKE_HOURS).

(TIME_STAMP_9) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

The next questions are about your experiences in the past year. First, I’d like to ask about some questions about work. People’s work situations sometimes change after having a baby.

MB003 (WORK_LAST_CONTACT) Since our last interview, have you been employed at a job or business?

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

MB004 (WORK_CURRENTLY) Are you currently employed?

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

MB008 (WORK_HRS) How many hours per week do you work?

|___|___|

HOURS

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

HB004 (R_SMOKE) Do you currently smoke cigarettes or use any other tobacco product?

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

HB006 (NUM_SMOKER) How many smokers live in your home now, {including yourself}?

PROGRAMMER INSTRUCTION: ADD bracketed text if R_SMOKE = 1

|___|___|

NUMBER OF SMOKERS

INTERVIEWER INSTRUCTION: ENTER “0” IF NONE.

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

HB010 (SMOKE_RULES) Which of the following statements describes the rules about smoking inside your home now?

No one is allowed to smoke anywhere inside my home,	………………………	1
Smoking is allowed in some rooms at some times, or	………………………	2
Smoking is permitted anywhere inside my home	………………………	3
REFUSED	………………………	-1
DON’T KNOW	………………………	-2

HB012 (SMOKE_HOURS) On average, about how many hours per day do people smoke in the same room as {C_FNAME or YOUR CHILD}, or near enough that {he/she} can see or smell the smoke? Please consider all the places {C_FNAME or YOUR CHILD} is during the day, including at home, at daycare, or some other place.

INTERVIEWER INSTRUCTION: IF {HE/SHE} IS NOT EXPOSED TO SMOKE, ENTER “0.”

|___|___|

HOURS

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

PROGRAMMER_INSTRUCTIONS:

1.) IF (CHILD_NUM) =1, GO TO (TIME_STAMP_10).

2.) IF CHILD_NUM >1, GO TO CHILD_QNUM AND LOOP THROUGH QUESTIONAIRE FROM IN011 THROUGH HB012 (SMOKE_HOURS) FOR EACH CHILD UNTIL (CHILD_NUM)=(CHILD_QNUM). THEN GO TO (TIME_STAMP_10).

Pets

PT001 (TIME_STAMP_10) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

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

PT003 (PETS) Are there any pets that spend any time inside your home?

YES	……………………………………………	1
NO	……………………………………………	2	(TIME_STAMP_11)
REFUSED	……………………………………………	-1	(TIME_STAMP_11)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_11)

PT005 (PET_TYPE) What kind of pets are these?

INTERVIEWER INSTRUCTION: PROBE FOR MULTIPLE RESPONSES; “Any others?”

DOG	…………….	1
CAT	…………….	2
SMALL MAMMAL (RABBIT, GERBIL, HAMSTER, GUINEA PIG, FERRET, MOUSE)	…………….	3
BIRD	…………….	4
FISH OR REPTILE (TURTLE, SNAKE, LIZARD)	…………….	5
OTHER	…………….	-5	(PET_TYPE_OTH)
REFUSED	…………….	-1
DON’T KNOW	…………….	-2

INTERVIEWER INSTRUCTION: SELECT ALL THAT APPLY.

PT007 (PET_TYPE_OTH) OTHER: SPECIFY

____________________________________________________________________

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

PT009 (PET_MEDS) Are any products ever used on your pets to control fleas, ticks, or mites? This includes flea collars, flea and tick powders, shampoos, or other flea, tick and mite control products. (This does not include pills given to your pet to control for fleas or other insects.)

YES	……………………………………………	1
NO	……………………………………………	2	(TIME_STAMP_11)
REFUSED	……………………………………………	-1	(TIME_STAMP_11)
DON’T KNOW	……………………………………………	-2	(TIME_STAMP_11)

PT011 ( PET_MED_TIME) When were any of these last used on any of your pets?

WITHIN THE LAST MONTH …………………………………………… 1

1-3 MONTHS AGO ……………………………………………………… 2

4-6 MONTHS AGO ……………………………………………………… 3

MORE THAN 6 MONTHS AGO ………………………………………. 4

REFUSED ……………………………………………………………….. -1

DON’T KNOW ………………………………………………………….. -2

In-Home Exposures

(TIME_STAMP_11) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

IHE001 Do you use any methods to “allergy-proof” your home? Please answer “yes” or “no” to each method I describe.

IHE010 (REMOVAL) Intentionally remove rugs or upholstered furniture?

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

IHE012 (METHOD) Any other methods?

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

IHE013 (METHOD_OTH) SPECIFY: ____________________________

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

IHE018 (OPEN_WINDOW) Thinking about the past 7 days, approximately how many hours a day did you keep the windows or doors open in your home (for ventilation or to let air in)? Was it…

Less than 1 hour per day,	……………………………………	1
1-3 hours per day,	……………………………………	2
4-12 hours per day,	……………………………………	3
More than 12 hours per day, or	……………………………………	4
Not at all?	……………………………………	5
REFUSED	……………………………………	-1
DON’T KNOW	……………………………………	-2

IHE020 I would now like to ask about cockroaches.

IHE047 (ROACH) In the last 6 months, have you seen cockroaches in your home?

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

IHE050 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.

IHE052 (WATER) In the last 6 months, have you seen any water damage inside your home?

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

IHE053 (MOLD) In the last 6 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	(IHE055B)
REFUSED	……………………………………………	-1	(IHE055B)
DON’T KNOW	……………………………………………	-2	(IHE055B)

IHE054 (ROOM_MOLD) In which rooms have you seen the mold or mildew?

KITCHEN	……………………………	1
LIVING ROOM	……………………………	2
HALL/LANDING	……………………………	3
YOUR CHILD’s BEDROOM	……………………………	4
OTHER BEDROOM	……………………………	5
BATHROOM/TOILET	……………………………	6
BASEMENT	……………………………	7
OTHER	……………………………	-5	(ROOM_MOLD_OTH)
REFUSED	……………………………	-1
DON’T KNOW	……………………………	-2

INTERVIEWER INSTRUCTION: SELECT ALL THAT APPLY.

PROBE: Any other rooms?

IHE055 (ROOM_MOLD_OTH) SPECIFY _____________________________

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

PROGRAMMER INSTRUCTION:

1. IF (ROOM_MOLD)=4, GO TO (ROOM_MOLD_CHILD). ELSE, GO TO IHE055B.

2. LOOP THROUGH (ROOM_MOLD_CHILD) UNTIL (CHILD_NUM)=(CHILD_QNUM).

IHE055A. (ROOM_MOLD_CHILD) Was the mold in {C_FNAME or YOUR CHILD} bedroom?

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

IHEO55B The next few questions ask about any recent additions or renovations to your home.

IHE056 (RENOVATE) In the last 6 months, 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	(TIME_STAMP_12)
REFUSED	………………………………………	-1	(TIME_STAMP_12)
DON’T KNOW	………………………………………	-2	(TIME_STAMP_12)

IHE057(RENOVATE_ROOM) Which rooms were renovated?

INTERVIEWER INSTRUCTION: SELECT ALL THAT APPLY. PROBE: Any others?

KITCHEN	……………………………	1
LIVING ROOM	……………………………	2
HALL/LANDING	……………………………	3
{C_FNAME or YOUR CHILD}’sBEDROOM	……………………………	4
OTHER BEDROOM	……………………………	5
BATHROOM/TOILET	……………………………	6
BASEMENT	……………………………	7
OTHER	……………………………	-5	(RENOVATE_ROOM_OTH)
REFUSED	……………………………	-1
DON’T KNOW	……………………………	-2

IHE058 (RENOVATE_ROOM_OTH) SPECIFY _____________________________

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

HOUSING CHARACTERISTICS

(TIME_STAMP_12) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

HC000. Now I’d like to find out more about your living situation.

NC003/(RECENT_MOVE). Have you moved or changed your housing situation since we contacted you last?

YES 1 (AGE_HOME)

NO 2 (TIME_STAMP_13)

REFUSED -1 (TIME_STAMP_13)

DON’T KNOW

……………………………………………

-2

(TIME_STAMP_13)

HC0400/(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

HC0500./(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

HC3400/(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

HC3400A. (WATER_DRINK_OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

HC3500/(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

HC3500A. (WATER_COOK _OTH)

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

Neighborhood Characteristics

NC001 Now I’d like to ask a few questions about your neighborhood.

NC004 (NEIGH_DEFN) When you are talking to someone about your neighborhood, what do you mean? Is it…

The block or street you live on,	………………………………………	1
Several blocks or streets in each direction,	………………………………………	2
The area within a 15 minute walk from your house, or	………………………………………	3
An area larger than a 15 minute walk from your house?	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC006 (NEIGH_FAM) How many of your relatives or in-laws live in your neighborhood?  Would you say…

None	………………………………………	1
A few	………………………………………	2
Many	………………………………………	3
Most	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC008 (NEIGH_FRIEND) How many of your friends live in your neighborhood?  Would you say…

None	………………………………………	1
A few	………………………………………	2
Many	………………………………………	3
Most	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC010 (NEIGHBORS) About how many adults do you recognize or know by sight in this neighborhood? Would you say you recognize …

None	………………………………………	1
A few	………………………………………	2
Many	………………………………………	3
Most	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC012 (NEIGH_NUM_TALK) In the past 30 days, that is since [INSERT DATE 30 DAYS AGO], how many of your neighbors have you talked with for 10 minutes of more? Would you say…

None	………………………………………	1
1 or 2	………………………………………	2
3 to 5	………………………………………	3
6 or more	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC014 (NEIGH_HELP) About how often do you and people in your neighborhood do favors for each other? By favors, we mean such things as watching each other’s children, helping with shopping, lending garden or house tools.

Often	………………………………………	1
Sometimes	………………………………………	2
Rarely	………………………………………	3
Never	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC016 (NEIGH_TALK) How often do you and other people in your neighborhood visit in each other’s homes or speak with each other on the street?

Often	………………………………………	1
Sometimes	………………………………………	2
Rarely	………………………………………	3
Never	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC018 (NEIGH_WATCH_1) If children were skipping school and hanging out, how likely is it that your neighbors would do something about it? Would you say it is …

Very Likely,	………………………………………	1
Likely,	………………………………………	2
Unlikely, or	………………………………………	3
Very Unlikely	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC020 (NEIGH_WATCH_2) If children were showing disrespect to an adult, how likely is it that your neighbors would do something about it? Would you say it is …

Very Likely,	………………………………………	1
Likely,	………………………………………	2
Unlikely, or	………………………………………	3
Very Unlikely	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC022 Please tell me if you agree or disagree with the following statements.

NC024(NEIGH_CLOSE) This is a close-knit neighborhood. Would you say you ….

Strongly agree,	………………………………………	1
Agree,	………………………………………	2
Disagree, or	………………………………………	3
Strongly disagree	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC026 (NEIGH_TRUST) People in this neighborhood can be trusted. Would you say you …

Strongly agree,	………………………………………	1
Agree,	………………………………………	2
Disagree, or	………………………………………	3
Strongly disagree	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC028 (NEIGH_SAFE_1) I feel safe walking in my neighborhood, day or night.

Strongly agree,	………………………………………	1
Agree,	………………………………………	2
Disagree, or	………………………………………	3
Strongly disagree	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC030 (NEIGH_SAFE_2) Violence is not a problem in my neighborhood.

Strongly agree,	………………………………………	1
Agree,	………………………………………	2
Disagree, or	………………………………………	3
Strongly disagree	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

NC032 (NEIGH_SAFE_3) My neighborhood is safe from crime.

Strongly agree,	………………………………………	1
Agree,	………………………………………	2
Disagree, or	………………………………………	3
Strongly disagree	………………………………………	4
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TRACING QUESTIONS

(TIME_STAMP_13) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TQ001 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.

TQ004 (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

TQ006 (HAVE_EMAIL). Do you have an email address?

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

TQ008 (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

TQ010 (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

TQ012 (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

TQ014 (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_14)
DON’T REMEMBER	………………………………………
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ016 (CELL_PHONE_1). Do you have a personal cell phone?

YES	………………………………………	1
NO	………………………………………	2	(TIME_STAMP_14)
REFUSED	………………………………………	-1	(TIME_STAMP_14)
DON’T KNOW	………………………………………	-2	(TIME_STAMP_14)

TQ018 (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

TQ020 (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)

TQ022 (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

TQ024 (CELL_PHONE). What is your personal cell phone number?

|___|___|___| - |___|___|___| - |___|___|___|___|

PHONE NUMBER

RESPONDENT HAS NO CELL PHONE	……………………………	-7
REFUSED	……………………………	-1
DON’T KNOW	……………………………	-2

(TIME_STAMP_14) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

TQ026 (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)
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

TQ028 (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)

(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.

Q030 (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	………………………	-5	(CONTACT_RELATE1 _OTH)
REFUSED	………………………	-1
DON’T KNOW	………………………	-2

TQ032 (CONTACT_RELATE1_OTH) SPECIFY _____________________________

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

TQ034 (CONTACT_ADDR_1). What is his/her address?

INTERVIEWER INSTRUCTION: 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

(CONTACT_PHONE_1) What is his/her telephone number?

|___|___|___| - |___|___|___| - |___|___|___|___|

PHONE NUMBER

CONTACT HAS NO PHONE	……………………………	-7
REFUSED	……………………………	-1
DON’T KNOW	……………………………	-2

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

TQ036 (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?

(CONTACT_FNAME_2)/(CONTACT_LNAME_2).

______________ __________________

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.

TQ038 (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	………………………	-5	(CONTACT_RELATE2 _OTH)
REFUSED	………………………	-1
DON’T KNOW	………………………	-2

(CONTACT_RELATE2_OTH) SPECIFY _____________________________

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

TQ040 (CONTACT_ADDR_2). What is his/her address?

INTERVIEWER INSTRUCTION: 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

TQ042 (CONTACT_PHONE_2) What is his/her telephone number?

|___|___|___| - |___|___|___| - |___|___|___|___|

PHONE NUMBER

CONTACT HAS NO PHONE	………………………	-7
REFUSED	……………………………	-1
DON’T KNOW	……………………………	-2

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

(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_15) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 30 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.