Form 20.1 Survey

ATTACHMENT A.1.1 Birth Instrument (EH, PB, HI) OMB #: 0925-0593

OMB Expiration Date: 7/31/2013

Birth Interview, Phase 2

Birth Interview (EH, PB, HI) V2.1

Event:	Birth
Participant:	Mother
Domain:	Questionnaire
Type of Document:	Interview
Recruitment Groups: Version: Release:	EH, PB, HI V2.1 MDES 2.2

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Birth Interview (EH, PB, HI) V2.1

TABLE OF CONTENTS

INTERVIEW INTRODUCTION 1

INTERVIEWER-COMPLETED QUESTIONS 1

BABY CHARACTERISTICS 3

HOUSING CHARACTERISTICS 8

ENVIRONMENTAL EXPOSURES 10

INFANT FEEDING 13

INFANT SLEEP 14

WELL BABY CARE AND IMMUNIZATIONS 17

WORK AND PLANS FOR CHILDCARE 18

TRACING QUESTIONS 21

INTERVIEWER-COMPLETED QUESTIONS 28

Birth Interview (EH, PB, HI) V2.1

INTERVIEW INTRODUCTION

(TIME_STAMP_1) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

VS001. Thank you for agreeing to participate in the National Children’s Study. This interview will take about 20 minutes. Your answers are important to us. There are no right or wrong answers. We will ask you about yourself, your baby’s birth, and your plans once you return home. You can skip over any question or stop the interview at any time. We will keep everything that you tell us confidential.

VS002. INTERVIEWER INSTRUCTIONS:

• IF ADDITIONAL INFORMATION IS NEEDED, SAY [You may be receiving government benefits, such as Social Security or Medicaid. Nothing will happen to those benefits if you decide to take part or not take part in this study.]

• CONTINUE UNLESS PARTICIPANT ASKS QUESTIONS OR REFUSES TO PARTICIPATE. IF PARTICIPANT REFUSES, DISPOSITION CONTACT AS A REFUSAL AND COMPLETE A NON-INTERVIEW REPORT.

INTERVIEWER-COMPLETED QUESTIONS

IC001/(BIRTH_DELIVER). WHERE DID PARTICIPANT DELIVER {BABY/BABIES}?

HOSPITAL, 1

BIRTHING CENTER, 2

AT HOME 3

SOME OTHER PLACE -5

PROGRAMMER INSTRUCTION:

• IF BIRTH_DELIVER = 3, GO TO MULTIPLE_NUM. OTHERWISE, GO TO RELEASE.

IC002/(RELEASE). {HAS BABY/HAVE BABIES} BEEN RELEASED FROM THE {HOSPITAL/BIRTHING CENTER/{OTHER PLACE}?

INTERVIEWER INSTRUCTIONS:

• ASK ONLY IF NEEDED.

• IF MULTIPLE BIRTH AND AT LEAST ONE BABY HAS BEEN RELEASED FROM HOSPITAL, SELECT “1” (“YES”).

YES 1

NO 2

PROGRAMMER INSTRUCTION:

• IF BIRTH_DELIVER = 1, DISPLAY “hospital”.

• IF BIRTH_DELIVER = 2, DISPLAY “birthing center”.

• IF BIRTH_DELIVER = -5, DISPLAY “other place”.

IC003/(MULTIPLE). WAS THIS A MULTIPLE BIRTH?

YES 1

NO 2 (CHILD_DOB)

PROGRAMMER INSTRUCTION:

• USE MULTIPLE TO CODE {BABY/BABIES} AND {BABY’S/BABIES’} FIELDS AS APPROPRIATE THROUGHOUT INSTRUMENT

• IF MULTIPLE=2, DISPLAY BABY.

• IF MULTIPLE=1, DISPLAY BABIES.

IC004/(MULTIPLE_NUM). HOW MANY BABIES WERE DELIVERED?

|___|___|

NUMBER

IC005/(CHILD_DOB). WHAT WAS THE {BABY’S/BABIES’} DATE OF BIRTH?

MONTH: |___|___|

M M

DAY: |___|___|

D D

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

BABY CHARACTERISTICS

PROGRAMMER INSTRUCTIONS:

• LOOP THROUGH QUESTIONS BABY_NAME THROUGH BABY_RACE FOR TOTAL NUMBER OF BABIES DELIVERED

• BASED ON NUMBER OF LOOPS, DISPLAY APPROPRIATE ADJECTIVES (E.G. “FIRST” OR “NEXT,” “BABY” OR “BABIES”)

BC001/(BABY_NAME). During this interview, we would like to refer to your {baby/babies} by name.

PROGRAMMER INSTRUCTIONS:

• If MULTIPLE = 1 AND MULTIPLE_NUM = 2 AND FIRST LOOP, DISPLAY: “Let’s start with your first twin birth. What name would you like me to use to talk about your first baby?”

• IF MULTIPLE = 1 AND MULTIPLE_NUM = 3 AND FIRST LOOP, DISPLAY: ““Let’s start with your first triplet birth. What name would you like me to use to talk about your first baby?”

• IF MULTIPLE = 1 AND MULTIPLE_NUM ≥ 4 AND FIRST LOOP, DISPLAY: ““Let’s start with your first higher order birth. What name would you like me to use to talk about your first baby?”

• IF MULTIPLE = 1 AND MULTIPLE_NUM = 2 AND SECOND LOOP, DISPLAY: “Now let’s talk about your next baby. What name would you like me to use to talk about your next baby?”

• IF MULTIPLE = 1 AND MULTIPLE_NUM ≥ 3 AND SECOND OR HIGHER LOOP, DISPLAY: “Now let’s talk about your next baby. What name would you like me to use to talk about your next baby?”

• IF MULTIPLE =2, DISPLAY: “What name would you like me to use to talk about your baby?”

NAME PROVIDED 1

INITIALS PROVIDED 2

NO OFFICIAL NAME SELECTED 3 (BABY_SEX)

REFUSED -1 (BABY_SEX)

DON’T KNOW -2 (BABY_SEX)

INTERVIEWER INSTRUCTION:

• ENTER TEXT AND CONFIRM SPELLING

_____________________

FIRST NAME

(BABY_FNAME)

REFUSED -1

DON’T KNOW -2

_____________

MIDDLE NAME

(BABY_MNAME)

REFUSED -1

DON’T KNOW -2

___________________

LAST NAME

(BABY_LNAME)

REFUSED -1

DON’T KNOW -2

BC007/(BABY_SEX). What is the sex of the baby?

MALE 1

FEMALE 2

BOTH 3

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF MULTIPLE =2 AND BABY_SEX=1, USE “he” and “him” IN REMAINDER OF QUESTIONNAIRE.

• IF MULTIPLE =2 AND IF BABY_SEX=2 USE “she” and “her” IN REMAINDER OF QUESTIONNAIRE.

• IF MULTIPLE=1, USE “they” IN REMAINDER OF QUESTIONNAIRE.

• IF MULTIPLE BIRTHS, PRE-FILL EITHER “your babies” OR ACTUAL NAMES – SEPARATED BY “and” AS APPROPRIATE THROUGHOUT QUESTIONNAIRE.

• IF MULTIPLE=2 AND IF BABY_SEX=3, -1 OR -2, USE BABY_NAME IN REMAINDER OF QUESTIONNARE FOR “he”, ‘him”, “she”, or “her."

• IF BABY_NAME=3, -1 OR -2 AND BABY_SEX=3, -1 OR -2, USE “your baby” IN REMAINDER OF QUESTIONNAIRE FOR “he”, ‘him”, “she”, or “her."

BC007A/(BABY_BWT_LB)/(BABY_BWT_OZ). How much did {BABY_NAME/your baby} weigh when {he/she} was born?

POUNDS: |___|___|

P P

OUNCES: |___|___|

O O

REFUSED -1

DON’T KNOW -2

BC007B/(ETHNICITY). Do you consider {BABY_NAME/your baby} to be Hispanic, or Latino?

YES 1

NO 2

REFUSED -1

DON’T KNOW -2

BC007C/(RACE). What race do you consider {BABY_NAME/your baby} to be? You may select one or more.

INTERVIEWER INSTRUCTIONS:

• IF USING SHOWCARDS, REFER PARTICIPANT TO APPROPRIATE SHOWCARD. OTHERWISE, READ RESPONSE CATEGORIES TO PARTICIPANT.

• SELECT ALL THAT APPLY.

• PROBE: Anything else?

WHITE, 1

BLACK OR AFRICAN AMERICAN, 2

AMERICAN INDIAN OR ALASKA NATIVE, 3

ASIAN 4

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 5

MULTI-RACIAL 6

SOME OTHER RACE -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• CODE “OTHER” ONLY IF VOLUNTEERED.

• IF RACE = ANY COMBINATION OF 1 THROUGH 5, GO TO LIVE_MOM.

• IF RACE = ANY COMBINATION OF 1 THROUGH 5, AND -5, GO TO RACE_OTH.

• IF RACE = -5, GO TO RACE_OTH.

• IF RACE = 6, -1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES AND GO TO LIVE_MOM.

BC007D/(RACE_OTH).

SPECIFY _____________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT FREE TEXT TO 255 CHARACTERS.

BC008/(LIVE_MOM). Does BABY NAME/your baby}/{Do your babies} live with you/{When {BABY’S NAME/your baby leaves/your babies leave} the hospital will {he/she/they} live with you?

YES 1 (TIME_STAMP_2)

NO 2

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF RELEASE = 2, DISPLAY: {When {{BABY NAME/your baby} leaves}/{your babies leave} the hospital, will {he/she/they} live with you?

• IF RELEASE=1 OR BIRTH_DELIVER = 3, DISPLAY: Does {[BABY_NAME]/your baby/Do your babies} live with you?

  • If MULTIPLE = 2, DISPLAY “{Does BABY NAME/your baby} live with you”.

  • IF MULTIPLE = 1, DISPLAY “Do your babies live with you”.

• IF RELEASE = 2, DISPLAY: When {BABY_NAME}/your baby/your babies} leave the hospital, will {he/she/they} live with you?

• If MULTIPLE = 2, DISPLAY “{BABY NAME/your baby} leaves”.

• IF MULTIPLE = 1, DISPLAY “your babies leave”.

BC009/(LIVE_OTH). {With whom {does he/she live} {do they live?}/ With whom will {he/she/they} live?

BABY’S FATHER 1

BABY’S GRANDPARENT(S) 2

OTHER FAMILY MEMBER 3

PLACING IN FOSTER CARE 4

PLACING FOR ADOPTION 5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER = 3 OR RELEASE=1, AND IF MULTIPLE=2, DISPLAY: With whom does {he/she} live?

• IF BIRTH_DELIVER = 3, OR RELEASE=1, AND IF MULTIPLE=1, DISPLAY: With whom do they live

• IF BIRTH_DELIVER = 1, 2, OR -5, OR IF RELEASE=2, DISPLAY: With whom will {he/she/they} live?

(TIME_STAMP_2). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

HOUSING CHARACTERISTICS

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

YES 1

NO 2 (TIME_STAMP_3)

REFUSED -1 (TIME_STAMP_3)

DON’T KNOW -2 (TIME_STAMP_3)

HC004/(OWN_HOME). Is your current home…

Owned or Being Bought By You or Someone in Your Household 1 (AGE_HOME)

Rented By You or Someone in Your Household, Or 2 (AGE_HOME)

Occupied without payment of rent? 3 (AGE_HOME)

SOME OTHER ARRANGEMENT -5

REFUSED -1 (AGE_HOME)

DON’T KNOW -2 (AGE_HOME)

HC005/(OWN_HOME_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

HC006/(AGE_HOME). Can you tell us when your home or building was built? Was it between…

INTERVIEWER INSTRUCTION:

• IF USING SHOWCARDS, REFER PARTICIPANT TO APPROPRIATE SHOWCARD. OTHERWISE, READ RESPONSE CATEGORIES TO PARTICIPANT.

PROGRAMMER INSTRUCTION:

• IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS. OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE PER BELOW.

2001 TO PRESENT, 1

1981 TO 2000, 2

1961 TO 1980, 3

1941 TO 1960, OR 4

1940 OR BEFORE 5

REFUSED -1

DON’T KNOW -2

HC007/(LENGTH_RESIDE)/(LENGTH_RESIDE_UNIT). How long have you lived in this home?

|___|___|

NUMBER

REFUSED -1

DON’T KNOW -2

WEEKS 1

MONTHS 2

YEARS 3

INTERVIEWER INSTRUCTION:

• ENTER IN NUMERIC VALUE AND SELECT ASSOCIATED UNIT OF TIME

PROGRAMMER INSTRUCTION:

• INCLUDE SOFT EDIT IF VALUE > 18 YEARS

HC010/(TIME_STAMP_3). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

ENVIRONMENTAL EXPOSURES

EX001/(RENOVATE). The next few questions ask about any recent additions or renovations to your home.

Since our last contact, 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 or wallpapering, carpeting, or refinishing floors.

YES 1

NO 2 (DECORATE)

REFUSED -1 (DECORATE)

DON’T KNOW -2 (DECORATE)

EX002/(RENOVATE_ROOM). Which rooms were renovated?

INTERVIEWER INSTRUCTION:

• SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

BABY’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF RENOVATE_ROOM=ANY COMBINATION OF 1 THROUGH 7, INCLUDING JUST ONE OF THOSE RESPONSES, GO TO DECORATE.

• IF RENOVATE_ROOM=ANY COMBINATION OF 1 THROUGH 7, AND -5, GO TO RENOVATE_ROOM_OTH.

• IF RENOVATE_ROOM= -5, GO TO RENOVATE_ROOM_OTH.

IF RENOVATE_ROOM=-1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES, AND GO TO DECORATE.

EX003/(RENOVATE_ROOM_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

EX004/(DECORATE). Since our last contact, were any smaller projects done in your home, such as painting, wallpapering, refinishing floors, or installing new carpet?

YES 1

NO 2 (SMOKE)

REFUSED -1 (SMOKE)

DON’T KNOW -2 (SMOKE)

EX005/(DECORATE_ROOM). In which rooms were these smaller projects done?

• SELECT ALL THAT APPLY.

KITCHEN 1

LIVING ROOM 2

HALL/LANDING 3

BABY’S BEDROOM 4

OTHER BEDROOM 5

BATHROOM/TOILET 6

BASEMENT 7

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF DECORATE_ROOM=ANY COMBINATION OF 1 THROUGH 7, INCLUDING JUST ONE OF THOSE RESPONSES, GO TO SMOKE.

• IF DECORATE_ROOM=ANY COMBINATION OF 1 THROUGH 7, AND -5, GO TO DECORATE_ROOM_OTH.

• IF RENOVATE_ROOM= -5, GO TO RENOVATE_ROOM_OTH.

• IF DECORATE_ROOM=-1 OR -2, DO NOT ALLOW ANY OTHER RESPONSES, AND GO TO SMOKE.

EX006/(DECORATE_ROOM_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

EX007/(SMOKE). Currently, do you or others in your household smoke cigarettes, cigarillos, cigars, pipes or other tobacco products?

YES 1

NO 2 (TIME_STAMP_4)

REFUSED -1 (TIME_STAMP_4)

DON’T KNOW -2 (TIME_STAMP_4)

EX008/(SMOKE_LOCATE). Do those who smoke usually smoke indoors, outdoors, or both indoors and outdoors?

INDOORS 1

OUTDOORS 2

BOTH 3

REFUSED -1

DON’T KNOW -2

EX009/(TIME_STAMP_4). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER ≠3 AND RELEASE=2 GO TO FED_BABY.

• ELSE, SKIP TO HOW_FED.

INFANT FEEDING

IF001/(FED_BABY). Have you fed {BABY’S NAME/your baby/your babies} since {his/her/their} birth?

YES 1

NO 2 (PLAN_FEED)

REFUSED -1 (PLAN_FEED)

DON’T KNOW -2 (PLAN_FEED)

IF002/(HOW_FED). How have you fed {BABY’S NAME/your baby/your babies}? Did you breast or bottle feed?

BREAST ONLY 1

BOTTLE ONLY 2

BOTH BREAST AND BOTTLE 3

OTHER -5

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF LIVE_MOM = 2, GO TO TR001. OTHERWISE, GO TO PLAN_FEED.

IF003/(PLAN_FEED). {Have you fed/Do you plan to feed} the {baby/babies} breast milk, formula or both?

BREAST MILK 1

FORMULA 2

BOTH BREAST MILK AND FORMULA 3

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF FED_BABY = 2, DISPLAY: Do you plan to feed the {baby/babies} breast milk, formula or both?

• ELSE DISPLAY: Have you fed the {baby/babies} breast milk, formula or both?

IF004/(TIME_STAMP_5). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER ≠3 AND RELEASE=2, GO TO POS_HOSP.

• ELSE, GO TO POS_HOME.

INFANT SLEEP

IS001/(POS_HOSP). Do the nurses here in the {hospital/birthing center/other place} usually put {[BABY’S NAME]/your baby} to sleep on {his/her/their stomach(s), back(s), or side{s}?

STOMACH 1

BACK 2

SIDE 3

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER = 1,DISPLAY “hospital”.

• If BIRTH_DELIVER = 2, DISPLAY “birthing center”.

• If BIRTH_DELIVER = -5, DISPLAY “other place”.

• IF MULTIPLE=1, DISPLAY “their stomachs, backs or sides”

• IF MULTIPLE =2, AND BABY_SEX=1, DISPLAY “his stomach, back or side”

• IF MULTIPLE =2, AND BABY_SEX=2, DISPLAY “her stomach, back or side”

• ELSE DISPLAY “their stomachs, backs or sides”

IS002/(POS_HOME). {In what position do you usually put {BABY NAME}/your baby/your babies} to sleep at home?}/ In what position do you plan to put {BABY’S NAME/your baby/your babies} to sleep at home?}

STOMACH 1

BACK 2

SIDE 3

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER = 3 OR RELEASE=1, DISPLAY: “In what position do you usually put {BABY NAME/your baby/your babies} to sleep at home?”

• IF RELEASE=2, DISPLAY: “In what position do you plan to put {BABY NAME/your baby/your babies} to sleep at home?”

IS003/(SLEEP_ROOM). When you go home from the {hospital/birthing center/other place} do you plan for {BABY’S NAME/your baby/your babies} to sleep…

In {his/her/their} own room, 1

In a room with other children, 2

In your bedroom, or 3

Another location? 4

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER = 3 OR RELEASE=1, AND IF MULTIPLE=2, DISPLAY: “Does BABY NAME/your baby/ sleep…”

• IF BIRTH_DELIVER = 3 OR RELEASE=1, AND IF MULTIPLE=1, DISPLAY: “Do your babies sleep…”

• IF BIRTH_DELIVER = 1 AND RELEASE=2, DISPLAY: “When you go home from the hospital do you plan for {BABY_NAME/your baby/your babies }] to sleep…”]

• IF BIRTH_DELIVER = 2 AND RELEASE=2, DISPLAY: “When you go home from the birthing center do you plan for {BABY_NAME/your baby/your babies }] to sleep…”]

• IF BIRTH_DELIVER = -5 AND RELEASE=2, DISPLAY: “When you go home from the other place do you plan for {BABY_NAME/your baby/your babies }] to sleep…”]

IS004/(BED). When you go home from the {hospital/birthing center/other place} do you plan for {BABY’S NAME/your baby/your babies} to sleep in …

A bassinette, 1 (TIME_STAMP_6)

A crib, 2 (TIME_STAMP_6)

A co-sleeper, 3 (TIME_STAMP_6)

An adult bed alone, 4 (TIME_STAMP_6)

An adult bed with you, 5 (TIME_STAMP_6)

An adult bed with another child, or 6 (TIME_STAMP_6)

Something else -5

REFUSED -1 (TIME_STAMP_6)

DON’T KNOW -2 (TIME_STAMP_6)

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER = 3 OR RELEASE=1, AND IF MULTIPLE=2, DISPLAY: “Does {[BABY NAME]/your baby} sleep in…”

• IF BIRTH_DELIVER = 3 OR RELEASE=1, AND IF MULTIPLE=1, DISPLAY: “Do your babies sleep in…”

• IF BIRTH_DELIVER = 1 AND RELEASE=2, DISPLAY: “When you go home from the hospital do you plan for {[BABY NAME]/your baby/your babies }] to sleep in…”

• IF BIRTH_DELIVER = 2 AND RELEASE=2, DISPLAY: “When you go home from the birthing center do you plan for {[BABY NAME]/your baby/your babies }] to sleep in…”

• IF BIRTH_DELIVER = -5 AND RELEASE=2, DISPLAY: “When you go home from the other place do you plan for {[BABY NAME]/your baby/your babies }] to sleep in…”

IS005/(BED_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

IS006/(TIME_STAMP_6). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTIONS:

• IF BIRTH_DELIVER = 3 OR RELEASE = 1, GO TO HCARE_YET.

OTHERWISE, GO TO HCARE.

WELL BABY CARE AND IMMUNIZATIONS

WB001(HCARE). Where {have you taken/do you plan to take} your new {baby/babies} for well-baby checkups?

Hospital Clinic 1 (VACCINE)

Health Department Clinic 2 (VACCINE)

Private doctor's office or Health Maintenance Organization (HMO) 3 (VACCINE)

Some other place …………………………………………… -5

REFUSED -1 (VACCINE)

DON'T KNOW -2 (VACCINE)

PROGRAMMER INSTRUCTIONS:

• IF HCARE_YET = 1, DISPLAY, “have you taken”

• IF HCARE_YET = 2,-1 OR -2, DISPLAY, “do you plan to take”

WB003/(HCARE_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTIONS:

• LIMIT TEXT TO 255 CHARACTERS.

• IF BIRTH_DELIVER = 3 OR RELEASE = 1, GO TO VACCINE_YET.

• OTHERWISE, GO TO VACCINE.

WB003/(VACCINE). Do you plan for your new {baby/babies} to have well-baby shots or vaccinations?

YES 1

YES, ON A DELAYED SCHEDULE 2

NO 3

REFUSED -1

DON’T KNOW -2

WB004/(TIME_STAMP_7). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

WORK AND PLANS FOR CHILDCARE

WCC001/(EMPLOY2). Are you currently employed?

YES 1

NO 2 (CHILDCARE)

REFUSED -1

DON’T KNOW -2

WCC002/(RETURN_JOB/RETURN_JOB_UNIT). When do you plan to return to your current job?

|___|___|

NUMBER

DAYS 1

WEEKS 2

MONTHS 3

YEARS 4

DOESN’T PLAN TO RETURN TO WORK -7

REFUSED -1

DON’T KNOW -2

INTERVIEWER INSTRUCTION:

• ENTER IN NUMERIC VALUE AND SELECT ASSOCIATED UNIT OF TIME

PROGRAMMER INSTRUCTION:

• INCLUDE SOFT EDIT IF VALUE > 1 YEAR OR >12 MONTHS OR > 52 WEEKS OR >365 DAYS.

WCC003. Next I would like to ask you a few questions about your plans for childcare.

WCC004/(CHILDCARE). Will {BABY’S NAME/your baby/your babies} receive regularly scheduled care from someone other than you or the {baby’s/babies’} father?

YES 1

NO 2 (TIME_STAMP_8)

REFUSED -1

DON’T KNOW -2

WCC005/(CCARE_TYPE). Please describe the type of setting in which most of the childcare will occur.

PARTICIPANTS HOME 1 (CCARE_WHO)

OTHER PRIVATE HOME 2 (CCARE_WHO)

CHILD CARE CENTER 3 (CCARE_WHO)

OTHER -5

REFUSED -1 (CCARE_WHO)

DON’T KNOW -2 (CCARE_WHO)

WCC006/(CCARE_TYPE_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

WCC007/(CCARE_WHO). Which best describes the person who will be caring for {BABY’S NAME/your baby/your babies}?

INTERVIEWER INSTRUCTION:

• IF USING SHOWCARDS, REFER PARTICIPANT TO APPROPRIATE SHOWCARD. OTHERWISE, READ RESPONSE CATEGORIES TO PARTICIPANT.

PROGRAMMER INSTRUCTION:

• IF USING SHOWCARDS, DISPLAY RESPONSE CATEGORIES IN ALL CAPITAL LETTERS. OTHERWISE, DISPLAY RESPONSE CATEGORIES AS MIXED UPPER/LOWER CASE PER BELOW.

YOUR MOTHER 1 (TIME_STAMP_8)

YOUR FATHER 2 (TIME_STAMP_8)

YOUR MOTHER IN-LAW 3 (TIME_STAMP_8)

YOUR FATHER IN-LAW 4 (TIME_STAMP_8)

GUARDIAN 5 (TIME_STAMP_8)

OTHER RELATIVE 6

FRIEND 7 (TIME_STAMP_8)

NANNY 8 (TIME_STAMP_8)

PROFESSIONAL IN HOME DAYCARE 9 (TIME_STAMP_8)

PROFESSIONAL CENTER BASED DAYCARE 10 (TIME_STAMP_8)

OTHER - 5 (CCARE_WHO_OTH)

REFUSED -1 (TIME_STAMP_8)

DON’T KNOW -2 (TIME_STAMP_8)

WCC008/(REL_CARE_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

WCC009/(CCARE_WHO_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

WCC010/(TIME_STAMP_8). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

TRACING QUESTIONS

TR001. These next few questions will help us to contact you again in the future.

TR002/(R_FNAME)/(R_LNAME). What is your full name?

INTERVIEWER INSTRUCTION:

• CONFIRM SPELLING OF FIRST NAME IF NOT PREVIOUSLY COLLECTED AND OF LAST NAME FOR ALL PARTICIPANTS.

_____________________ ___________________

FIRST NAME LAST NAME

REFUSED -1

DON’T KNOW -2

TR003/(PHONE_NBR). What is the best phone number to reach you?

INTERVIEWER INSTRUCTION:

• ENTER PHONE NUMBER AND CONFIRM.

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

REFUSED -1 (HOME_PHONE)

DON’T KNOW -2 (HOME_PHONE)

PARTICIPANT HAS NO TELEPHONE/
NOT APPLICABLE ……. -7 (HOME_PHONE)

• TR004 INTERVIEWER INSTRUCTION:

• IF PARTICIPANT DOES NOT HAVE A TELEPHONE NUMBER, ASK WHERE PARTICIPANT RECEIVES TELEPHONE CALLS, EVEN IF SHE DOES NOT HAVE HER OWN PHONE. ASK FOR AND RECORD THAT NUMBER.

TR005/(PHONE_TYPE). Is that your home, work, cell, or another phone number?

INTERVIEWER INSTRUCTION:

• CONFIRM IF KNOWN.

HOME 1 (CELL_PHONE_1)

WORK 2 (HOME_PHONE)

CELL 3 (HOME_PHONE)

FRIEND/RELATIVE 4

OTHER -5 (PHONE_TYPE_OTH)

REFUSED -1 (HOME_PHONE)

DON’T KNOW -2 (HOME_PHONE)

TR006/(FRIEND_PHONE_OTH).

SPECIFY ________________________ (HOME_PHONE)

REFUSED -1 (HOME_PHONE)

DON’T KNOW -2 (HOME_PHONE)

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

TR007/(PHONE_TYPE_OTH).

SPECIFY ________________________

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

TR008/(HOME_PHONE). What is your home phone number?

• INTERVIEWER INSTRUCTION:

• ENTER PHONE NUMBER AND CONFIRM.

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

NO HOME NUMBER 1

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• IF PHONE_TYPE = 3 THEN GO TO CELL_PHONE_2. OTHERWISE, GO TO CELL_PHONE_1.

TR009/(CELL_PHONE_1). Do you have a personal cell phone?

YES 1

NO 2 (HAVE_EMAIL)

REFUSED -1 (HAVE_EMAIL)

DON’T KNOW -2 (HAVE_EMAIL)

TR016/(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

TR017(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)

TR018/(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

PROGRAMMER INSTRUCTION:

• IF PHONE_TYPE = 3 AND VALID NUMBER PROVIDED IN PHONE_NBR GO TO HAVE_EMAIL. OTHERWISE, GO TO CELL_PHONE.

TR019/(CELL_PHONE). What is your personal cell phone number?

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

PHONE NUMBER

REFUSED -1

DON’T KNOW -2

TR020/(HAVE_EMAIL). Do you have an email address?

YES 1

NO 2 (TIME_STAMP_9)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

TR021/(EMAIL). What is the best email address to reach you?

ENTER E-MAIL ADDRESS: ___________________________

(EMAIL_TYPE)

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

PROGRAMMER INSTRUCTION:

• SHOW EXAMPLE OF VALID EMAIL ADDRESS SUCH AS [email protected]

• LIMIT FREE TEXT TO 100 CHARACTERS.

TR023(EMAIL_TYPE). Is that your personal e-mail, work e-mail, or a family or shared e-mail address?

PERSONAL 1 (TIME_STAMP_9)

WORK 2 (TIME_STAMP_9)

FAMILY/SHARED 3

REFUSED -1 (TIME_STAMP_9)

DON’T KNOW -2 (TIME_STAMP_9)

TR027/(EMAIL_SHARE).

PROGRAMMER INSTRUCTIONS:

• IF PARTICIPANT REPORTED A SHARED EMAIL ADDRESS IN EMAIL_TYPE, SET EMAIL_SHARE AS APPROPRIATE THEN GO TO TIME_STAMP_9.

YES 1

NO 2

(TIME_STAMP_9) PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

PROGRAMMER INSTRUCTION:

• IF RECENT_MOVE = 1 THEN GO TO MOVE_INFO. ELSE GO TO SAME_ADDR.

TR024/(MOVE_INFO). What is the address of your new home?

ADDRESS KNOWN 1

OUT OF THE COUNTRY 2 (SAME_ADDR)

PO BOX ADDRESS ONLY 3 (MAILING_ADDRESS_VARIABLES)

REFUSED -1 (SAME_ADDR)

DON’T KNOW -2 (SAME_ADDR)

TR025/(NEW ADDRESS VARIABLES).

INTERVIEWER INSTRUCTION:

• PROBE AND ENTER AS MUCH INFORMATION AS PARTICIPANT KNOWS.

_____________________________________________________

(NEW_ADDRESS1) ADDRESS 1 - STREET

_____________________________________________________

(NEW_ADDRESS2) ADDRESS 2

_____________________________________________________

(NEW_UNIT) UNIT

____________________________________________________

(NEW_CITY) CITY

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

STATE ZIP CODE ZIP+4

(NEW_STATE) (NEW_ZIP) (NEW_ZIP4)

REFUSED -1

DON’T KNOW -2

TR026/(SAME_ADDR). Is your mailing address the same as your street address?

YES 1 (PLAN_MOVE)

NO 2

REFUSED -1 (PLAN_MOVE)

DON’T KNOW -2 (PLAN_MOVE)

TR027/(MAILING_ADDRESS_VARIABLES). What is your mailing address?

INTERVIEWER INSTRUCTION:

• PROMPT AS NECESSARY TO COMPLETE INFORMATION

_____________________________________________________

(MAIL_ADDRESS1) ADDRESS 1 - STREET/PO BOX

_____________________________________________________

(MAIL_ADDRESS2) ADDRESS 2

_____________________________________________________

(MAIL_UNIT) UNIT

____________________________________________________

(MAIL_CITY) CITY

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

STATE ZIP CODE ZIP+4

(MAIL_STATE) (MAIL_ZIP) (MAIL_ZIP4)

REFUSED -1

DON’T KNOW -2

TR028/(PLAN_MOVE). Do you plan on moving from your present address in the next few months?

YES 1

NO 2 (TIME_STAMP_10)

REFUSED -1 (TIME_STAMP_10)

DON’T KNOW -2 (TIME_STAMP_10)

TR029/(WHERE_MOVE). Do you know where you will be moving?

YES 1

NO 2 (WHEN_MOVE)

REFUSED -1 (WHEN_MOVE)

DON’T KNOW -2 (WHEN_MOVE)

TR030/(PLAN_MOVE_INFO). What is the address of your new home?

ADDRESS KNOWN 1

OUT OF THE COUNTRY 2 (WHEN_MOVE)

PO BOX ADDRESS ONLY 3

REFUSED -1 (WHEN_MOVE)

DON’T KNOW -2 (WHEN_MOVE)

TR031//(NEW ADDRESS VARIABLES_B). ENTER ADDRESS

• INTERVIEWER INSTRUCTION:

• PROBE AND ENTER AS MUCH INFORMATION AS PARTICIPANT KNOWS.

_____________________________________________________

(NEW_ADDRESS1_B) ADDRESS 1 - STREET

_____________________________________________________

(NEW_ADDRESS2_B) ADDRESS 2

_____________________________________________________

(NEW_UNIT_B) UNIT

____________________________________________________

(NEW_CITY_B) CITY

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

STATE ZIP CODE ZIP+4

(NEW_STATE_B) (NEW_ZIP_B) (NEW_ZIP4_B)

REFUSED -1

DON’T KNOW -2

TR032/(WHEN_MOVE). Do you know when you will be moving?

YES 1

NO 2 (TIME_STAMP_10)

REFUSED -1 (TIME_STAMP_10)

DON’T KNOW -2 (TIME_STAMP_10)

TR033/(DATE_MOVE). When will you move?

MONTH: |___|___|

M M

YEAR: |___|___|___|___|

Y Y Y Y

REFUSED -1

DON’T KNOW -2

PROGRAMMER INSTRUCTION:

• FORMAT DATE_MOVE AS YYYYMM

TR034//(TIME_STAMP_10). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

TR035/(END_OF_INTERVIEW). Thank you for participating in the National Children’s Study and for taking the time to answer our questions.

INTERVIEWER-COMPLETED QUESTIONS

IC001/(TIME_STAMP_11). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

IC002/(PARTICIPANT). WAS THE INTERVIEW COMPLETED WITH THE BIRTH MOTHER OR A PROXY?

BIRTH MOTHER 1

PROXY 2

IC003/(CONTACT_TYPE). IN WHAT MODE WAS THE QUESTIONNAIRE ADMINISTERED?

IN-PERSON 1

TELEPHONE 2

MAIL 3

WEB 4

IC004/(ENGLISH). WAS THIS DATA COLLECTION SESSION CONDUCTED IN ENGLISH?

YES 1 (INTERPRET)

NO 2

IC005/(CONTACT_LANG). WHAT OTHER LANGUAGE WAS USED TO CONDUCT THIS SESSION?

SPANISH 1 (INTERPRET)

ARABIC 2 (INTERPRET)

CHINESE 3 (INTERPRET)

FRENCH 4 (INTERPRET)

FRENCH CREOLE 5 (INTERPRET)

GERMAN 6 (INTERPRET)

ITALIAN 7 (INTERPRET)

KOREAN 8 (INTERPRET)

POLISH 9 (INTERPRET)

RUSSIAN 10 (INTERPRET)

TAGALOG 11 (INTERPRET)

VIETNAMESE 12 (INTERPRET)

URDU 13 (INTERPRET)

PUNJABI 14 (INTERPRET)

BENGALI 15 (INTERPRET)

FARSI 16 (INTERPRET)

OTHER -5

IC006/(CONTACT_LANG_OTH).

SPECIFY ________________________

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

IC007/(INTERPRET). WAS AN INTERPRETER USED?

YES 1

NO 2 (TIME_STAMP_12)

IC008/(CONTACT_INTERPRET). WHAT TYPE OF INTERPRETER WAS USED?

BILINGUAL INTERVIEWER 1 (TIME_STAMP_12)

IN-PERSON PROFESSIONAL INTERPRETER 2 (TIME_STAMP_12)

IN-PERSON FAMILY MEMBER INTERPRETER 3 (TIME_STAMP_12)

LANGUAGE-LINE INTERPRETER 4 (TIME_STAMP_12)

VIDEO INTERPRETER 5 (TIME_STAMP_12)

SIGN LANGUAGE INTERPRETER 6 (TIME_STAMP_12)

OTHER -5

IC009/(CONTACT_ INTERPRET_OTH).

SPECIFY ________________________

PROGRAMMER INSTRUCTION:

• LIMIT TEXT TO 255 CHARACTERS.

IC010/(TIME_STAMP_12). PROGRAMMER INSTRUCTION:

• INSERT DATE/TIME STAMP

INTERVIEWER INSTRUCTION:

• EXPLAIN INFANT AND CHILD HEALTH CARE LOG

ICL001. In order to help keep track of your child’s doctor visits or other health care provider visits, we are providing you with an Infant and Child Health Care Log. At each Study visit or telephone interview, we will ask you about any health care visits your child had since the last Study visit or telephone interview. This log will help you remember that information.

The Infant and Child Health Care Log is very similar to the Pregnancy Health Care Log, and will be used the same way. The only difference is the addition of the Immunization/Vaccination/Shot Log which is where all of your child’s vaccination information will need to be written down.

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

Public reporting burden for this collection of information is estimated to average 16 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.