Formative - Developmental

ATTACHMENT C.2.3

EXEMPLAR DEMOGRAPHICS QUESTIONNAIRE, NON-NCS PARTICIPANTS OMB #: 0925-0593

LOI3-PHYS-02 Expiration Date: July 31, 2013

(affix label here)

PERINATAL HISTORY

The purpose of this questionnaire is to learn more about growth among newborns, infants, and children. We ask the mother of the newborn, infant, or child to complete this questionnaire.

SOCIO-DEMOGRAPHICS
I’d like to ask about your marital status. What is your current marital status? Are you: Married 1 Not married but living together with a partner 2 Widowed 4 Divorced 5 Separated 6 Never been married 7 REFUSED 9--97 DON’T KNOW 9--98
Do you consider yourself to be Hispanic, or Latina? YES 1 NO 2 REFUSED 9--97 DON’T KNOW 9--98
What race do you consider yourself to be? You may select one or more. SELECT ALL THAT APPLY. White, 1 Black or African American, 2 American Indian or Alaska Native 3 Asian or Native Hawaiian or other Pacific Islander 4 REFUSED 9--97 DON’T KNOW 9--98
Does the father of the newborn, infant, or child consider himself to be Hispanic, or Latino? YES 1 NO 2 REFUSED 9--97 DON’T KNOW 9--98
What race does the father of the newborn, infant, or child consider himself to be? You may select one or more. SELECT ALL THAT APPLY. White, 1 Black or African American, 2 American Indian or Alaska Native 3 Asian or Native Hawaiian or other Pacific Islander 4 REFUSED 9--97 DON’T KNOW 9--98
Please look at the card and tell me 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
Were you born in the United States? YES 1 NO 2 REFUSED 9--97 DON’T KNOW 9--98

This part of this questionnaire asks about newborn, infant, or child’s birth weight, length and type of feeding received during early life.

Child’s History
What is [PARTICIPANT]’s birth name? (Last name, First name and Middle name)
What was [PARTICIPANT]’s weight at birth? |___|___| |___|___| Pounds Ounces REFUSED -1 DON’T KNOW -2
What was [PARTICIPANT]’s length at birth? |___|___| . |___|___| Inches REFUSED -1 DON’T KNOW -2

11. What is [PARTICIPANT’S] date of birth?

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

Month Day Year

REFUSED -1

DON’T KNOW -2

12. What is [PARTICIPANT’S] sex?

MALE 1

FEMALE 2

REFUSED -1

DON’T KNOW -2

13. Was [PARTICIPANT] born earlier or later than expected?

On time 1

Less than 2 weeks late 2

More than 2 weeks late 3

Less than 2 weeks early 4

More than 2 weeks early 5

REFUSED 9--97

DON’T KNOW 9--98

The next part of the questionnaire asks about your pregnancy with [PARTICIPANT].

Mother’s History
32. What is your date of birth? |___|___| |___|___| |___|___|___|___| Month Day Year REFUSED -1 DON’T KNOW -2
33. How tall are you without shoes? |___|___| |___|___| Feet Inches REFUSED -1 DON’T KNOW -2
34. What was your birth weight in pounds (lbs)? Less than 5.5 lbs 1 5.5 – 6.9 lbs 2 7-8.4 lbs 3 8.5-9.9 lbs 4 10 lbs or more 5 REFUSED 9--97 DON’T KNOW 9--98
35. How much do you weigh without shoes and in no/light clothing? |___|___|___| Pounds REFUSED -1 DON’T KNOW -2
36. Just before you got pregnant with [PARTICIPANT], how much did you weigh? |___|___|___| Pounds REFUSED -1 DON’T KNOW -2
37. Approximately, how much weight did you gain during this pregnancy? (Mark one) Less than 10 pounds 1 10-14 pounds 2 15-19 pounds 3 20-29 pounds 4 30-40 pounds 5 More than 40 pounds 6 REFUSED 9--97 DON’T KNOW 9--98

 This is the end of the interview. Do you have any questions or comments?
	1 No
	2 Yes, no review needed
	3 Yes, review needed
	C omments:
 Thank you for completing this interview.

FOR STUDY USE ONLY

Interview Assessment:

1. How much difficulty did the Patient have in understanding the interview questions?

 None

 Slight

 Moderate

 A Great Deal

 Don’t know

2. Were there significant problems with the interview?

 Yes

 No

If yes describe:

D ate Completed

Month Day Year

Completed by

Mode of Administration

1 In-Person

1 Telephone

D ate Reviewed

Month Day Year

Reviewer Code

D ate Entered

Month Day Year

Data Entry Code

Public reporting burden for this collection of information is estimated to average 5 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.